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Based on interviews, record review, and review of the facility's policies and documents, it was determined the facility failed to protect and promote patient rights, prevent physical abuse, and provide care in a safe setting for one (1) of twelve (12) sampled patients. Patient #1 was admitted to the Psychiatric Unit and placed in a closed seclusion room on 02/06/16 after evaluation in the Emergency Department (ED). The patient was brought to the ED by the police due to the patient having been found wandering in the street, barefoot, and acting incoherent. The ED listed the chief complaint to be the patient was delusional with hallucinations. A drug screen was performed and the patient tested positive for amphetamine and marijuana (THC). A seventy-two (72) hour hold was obtained for treatment. Once the patient was admitted to the Psychiatric Unit, the patient became aggressive and violent with the staff. The patient attacked two Security Officers and a nurse. During the altercation, Security Officer #1 and Registered Nurse (RN) #2 was witnessed to strike the patient in the face several times with a closed fist. The patient sustained a fractured nose and laceration to the forehead that required sutures.

In addition, the facility failed to ensure the nursing staff were properly trained to control a crisis situation and the facility failed to implement appropriate Crisis Situation Management (CSM) techniques and found the staff involved in the altercation with Patient #1 had not been properly trained. The Security Officers had not received abuse training and review of the abuse training provided to the nurses revealed employee to patient abuse was not discussed. Interviews with staff revealed the alleged physical abuse was reported to the House Manager and written statements were obtained. However, the manager failed to report the alleged abuse to the Administrative On-Call person and the facility did not report the alleged abuse to the Department of Community Based Services (DCBS) until 02/10/16, four (4) days after the alleged abuse occurred. Security Officer #1 and RN #2 were allowed to work after the alleged abuse and were in contact with the patient.

The facility identified the event to be a serious safety event and the investigation was still ongoing during the survey. The facility identified a root cause analysis that staff were not properly trained, the abuse policy was not clear regarding reporting, and corrective actions had not been implemented.

The facility's failure to ensure Patient #1 received care in a safe setting, ensure patients were not abused, to train staff on CSM and abuse reporting, and failure to report the alleged abuse and implement corrective actions placed Patient #1 and all patients in the facility at risk for serious injury, harm, impairment or death.


Refer to A144, A145, and A397.

Based on observation, interviews, record review, and review of the facility's policies and documents, it was determined the facility failed to ensure patients were free from abuse for one (1) of twelve (12) sampled patients. Patient #1 was admitted to the Psychiatric Unit for an involuntary seventy-two (72) hour hold for close monitoring of drug induced Psychosis on 02/06/16. Staff interviews and nursing assessments revealed the patient was religiously preoccupied and in an agitated state. The patient was placed in a locked seclusion room and given medication to help calm the patient. The patient became aggressive toward Security Officer #1 and then attacked the officer. There was a struggle with the patient. During the struggle two Security Officers and the patient was brought down to the floor. It was witnessed that Security Officer #1 placed the patient in a head lock and hit the patient in the face several times with his closed fist. The patient sustained a fracture nose and laceration to the forehead that required sutures in the Emergency Department (ED). In addition, Registered Nurse (RN) #2 was witnessed to hit the patient in the face during the altercation with the patient. RN #1 reported the alleged physical abuse to the House Manager on 02/06/16; however, he failed to investigate the allegation or report the allegation to Administrative staff according to the facility's Abuse Policy until 02/08/16. The facility failed to report the alleged abuse to the State Agency until 02/10/16, four days after the alleged abuse occurred. Security Officer #1 and Registered Nurse (RN) #2 were allowed to work with the patient after the alleged abuse had occurred.


In addition, the facility failed to implement appropriate Crisis Situation Management (CSM) techniques and failed to report the alleged abuse to the appropriate State Agency and protect the patient from further abuse.

Refer to A144, A145, and A397.


The findings include:

1. Review of the facility's Abuse Policy, revised date of 08/20/14 and 11/18/14, revealed the purpose of the Abuse Policy was to protect patient's rights to be free from abuse and to establish appropriate procedures for responding to reports of abuse, neglect, or exploitation. The policy stated the patient had a right to be free from verbal, physical, mental, or other abuse, including neglect and exploitation. Such abuse would not be tolerated from any employee, volunteer, student, physician, patient, visitor, or other individual. Under the definition of physical abuse included but not limited to, hitting, slapping, punching and kicking. Physical abuse also included controlling a patient's behavior through corporal punishment. Allegations made against a facility employee must be reported by the first person becoming aware of the allegation. That person would notify the Department/Unit Manager or House Manager who would ensure that immediate measures necessary are taken for patient safety, and then notify the following persons: Department Director; Vice President; Administrator On-Call; Attending Physician; Director of Risk Management; and Social Services (who report the allegation to the Department of Protection and Permanency as appropriate). The Department/Unit Manager or House Manager would obtain a detailed statement from the patient/family member making the allegation. There was nothing in the policy to direct staff on what to do if they observed an employee abuse a patient. The policy stated generally, an employee was suspended pending further investigation of allegations of patient abuse.

Review of the Abuse Policy specific to the Psychiatric Unit, revised date 10/26/15, revealed this policy applied to all trained care providers and Psychiatric Unit staff. The procedure stated nursing would complete assessment of patient's report of abuse. Nursing would document all available information in the medical record including nature of the reported abuse, time it occurred, and injuries received. Nursing would inform the Social Worker and if unable to reach, leave a message. The Social Worker evaluates the patient's report, makes referrals, and documents the referral. A reporting form was attached to this policy that was designed for abuse allegations which occurred outside the facility such as domestic violence and not for employee to patient abuse.

Review of the Department for Community Based Services (DCBS) tracking ID intake form revealed the facility notified the state agency of the allegation of physical abuse, on 02/10/16 at 3:35 PM, four days after the alleged abuse had occurred.

Review of the Patient's Rights for Protective Service Policy, reviewed 06/30/14 and revised May 2012, revealed the purpose of the policy was to provide patients information/services necessary to ensure their protection related to Abuse/Neglect and Exploitation. The policy referenced KRS 209.30.

Review of the Assault or Violent Behavior Policy, revised 10/26/15, revealed the policy was created specific for the Psychiatric Unit. The purpose was to ensure nursing was knowledgeable of behavior indicating potentially dangerous situations. The policy applied to all trained care providers, Psychiatric Unit staff, and Security Department staff. Stage I of the policy instructed staff to be alert to patients posing a higher risk of violent behaviors that included paranoia, inability to concentrate, increased voice volume, substance withdrawal, and psychosis-auditory or visual hallucinations. The key point was to notify the physician of escalating behaviors. Stage II was to call a "Code Man". Staff members participating in a "Code Man" are well trained in body mechanics and methods of holding a struggling patient without causing injury; maintaining a comfortable distance (beyond the reach of hands/feet) from the patient; face the patient and maintain an exit at your back; only one person should talk with the patient; a staff member would be assigned to restrain each limb. When a patient's out of control state is acknowledged, tell the patient the staff are prepared to maintain control of him/her until they regain self-control. Tell the patient what you want them to do. Use the least amount of force necessary. Try to appear calm and in control. Do not show anger. If physical restraints are used, move without hesitation in an organized manner restraining all limbs. Explain to the patient that control was being maintained for them until self-control can be restored. Document clearly the mental status of the patient and threat of danger posed for themselves or others. Document interventions attempted to decelerate the patient, but were unsuccessful. If there were injuries to the patient, staff, or visitors, fill out an incident report.

Review of the facility's Code Man Policy, revised March 2011, revealed the purpose of the policy was to recruit assistance in preventing a non-armed, agitated, confused, and/or combative person from causing injury to self or others. Crisis Situation Management (CSM) training was provided for responders from the Security Department, Emergency Department, Plant Engineering Department, and designated staff from Environmental Services. Staff responding from other departments (Nursing and Transport) respond for manpower purposes (i.e. assist with physical control of combative person) under direct supervision of CSM trained personnel. Available Security personnel and trained CSM personnel respond to the announced location as quickly and safely as possible. If the situation is determined to be a medical crisis, nursing staff direct the actions of the responders, if the situation becomes threatening to staff, Security directs the action of the responders. In the event injury occurred to the patient, staff, or visitor, a reportable event form would be completed. Employees are sent to the ED or Employee Health.

Review of the facility's Patient Rights and Responsibly Policy, revision date of March 2012 and reviewed date of 04/23/14, revealed the purpose of the policy is to inform, promote, and protect the basic rights of the patients to treatment, care, and services within the facility's capability and mission in compliance with applicable laws and regulations. The policy stated the patient had the right to receive fair compassionate care at all times and under all circumstances. The patient had the right to receive care in a safe setting, to be free from abuse and harassment, and have access to protective services as needed.

Review of Patient #1's clinical record revealed the patient was brought to the Emergency Department (ED) on 02/06/16 at 4:41 PM via the police. According to the ED physician's clinical report, the police had found the patient wandering in the street barefoot and acting incoherent. The patient was making statements about being Jesus and exhibited unusual behavior. The chief complaint listed was withdrawal with delusions and hallucinations. This had started the night before. The physician documented the patient's symptoms were described as severe. A drug screen was performed and the patient tested positive for amphetamines and marijuana (THC).

Review of the History and Physical, dated 02/07/16, revealed the patient was admitted to the Psych Unit on a seventy-two (72) hour hold, after in the ED the patient was noted to be psychotic, very paranoid and attempted to leave the ED. Upon admission to the Psych Unit, the patient appeared to be very apprehensive. The physician ordered medication that included Haldol, Benadryl and Ativan. The patient accepted the medications. Suddenly, the patient became agitated and aggressive and began kicking, punching, and fighting the security officers. During this encounter, the patient was injured, that included forehead laceration and nose bleed. A Computerized Tomography (CT) scan revealed the patient sustained a nose fracture of the right nasal bone and required sutures for the laceration to the forehead. The attending physician interviewed the patient the next day (02/07/16) and the patient said he/she remembered bits and pieces of what happened to him/her. The patient told the physician he/she experienced visual and auditory hallucinations and felt very scared and apprehensive. The physician documented the patient's insight, judgment, and impulse control as significantly impaired. Diagnostic impression severe drug use of amphetamine and marijuana and substance-induced psychosis.

Review of the Hospitalist's consult documentation (on 02/07/16) to evaluate Patient #1's injuries after the altercation with the security officers, revealed jagged laceration to the forehead with edema and tenderness. In addition, the nasal bones were assessed to be swollen into the bilateral super maxillary soft tissue. Contusions were noted on the left mid-calf and right posterior elbow. The Hospitalist documented the patient had multiple abrasions and contusions. He requested the patient's laceration to the forehead be treated in the ED.
Review of the ED records revealed physical restraints were applied, on 02/06/16 at 6:10 PM, due to the patient bolting out of the ED room. The local police were in the ED (for another reason) and assisted the patient back in the ED bed. The reason for the physical restraints was the patient exhibited violent behavior including imminent risk of harm to self or others. Four-point restraints were applied. The one hour face to face restraint assessment was performed at 7:55 PM and documented the patient was agitated and confused.

Review of the nursing admission note, dated 02/06/16, revealed Patient #1 was admitted to the Psychiatric Unit at 8:45 PM under an involuntary seventy-two (72) hour hold with a diagnosis of Drug Induced Psychosis. Report from the ED nurse stated the patient had history of Psychosis and Substance Abuse. The nurse reported the patient's eyes were dilated and the drug screen test was positive for amphetamine and marijuana. The nurse documented the patient had bolted out of the exam room, but was returned and placed in physical restraints. The patient arrived on the Psychiatric Unit in a wheelchair accompanied by two Security Officers. The patient was taken to the Seclusion Room for assessment. The patient initially resisted moving from the wheelchair to the bed, but did with several directions and reassurance from staff. The patient was religiously preoccupied stating the nurse was the devil and asked that staff kill him/her because he/she needed to die for them. Due to the patient's psychotic agitated state, medication was ordered and admistered. The patient was given Haldol 5 mg (1), Benadryl 50mg (1), and Ativan 2 mg (1) via mouth. The patient took the medication with some hesitation at 9:50 PM. The patient was placed in seclusion due to the agitation and psychosis. The nurse left the seclusion room then returned to perform vital signs and a physical assessment. The door to the Seclusion Room had been locked with both Security Officers present in the Transition (Ante) Room. The patient was cooperative at that time. RN #1 returned to the nurses' station leaving RN #2 and the two Security Officers in the seclusion room with the patient. While at the nurses' station, RN #1 saw the patient stand up on the bed from the monitors at the Nurses' Station. The nurse documented she went to the Seclusion Room to assess the situation. She found one Security Officer struggling with the patient on the floor. A Code Man was called due to out of control and aggressive behaviors. The patient was placed back into seclusion with one to one staff monitoring.

On 02/17/16 at 12:36 PM, a meeting was held with the following facility Administrative staff: Chief Executive Officer; Director of Compliance; Vice President; Chief Nursing Officer; Director of Risk Management; Director of Quality Management; and Chief Medical Officer. The Director of Risk Management conducted the facility's internal investigation of the alleged physical abuse. He stated he learned of the alleged abuse on 02/08/16 after reading written statements from facility staff working the night of the alleged abuse. He stated he immediately set up interviews with all staff involved. He stated after those interviews, it was the first time there was an indication of abuse. He stated the interviews with RN #1 and Security Officer #2, on 02/09/16, revealed they had witnessed the alleged abuse and he learned Patient #1 had sustained injury. On 02/10/16, the Administrative staff determined the need to report the alleged abuse to the State Agency-DCBS.

The Director of Risk Management stated a report given to him revealed the patient had become extremely violent and had injured two Security Officers and RN #2. The report revealed the patient had sustained injury, but indicated the injuries were sustained during the struggle with staff. The report stated the patient had been struck in the act of trying to restrain the patient. The report stated it took three (3) big men to contain the patient. The House Manager voiced concern about the patient getting out of hand again. The patient was seen by a Hospitalist to assess the patient's injuries. The Hospitalist ordered a CT scan that revealed a nasal fracture and ordered for the patient to be seen in the ED for the laceration to the forehead that required sutures. A psychiatric consult was ordered for a possible transfer to another psychiatric hospital. The Risk Manager stated RN #1 reported what she witnessed to the House Manager and he informed the Administrator On-Call (Chief Medical Officer). The alleged abuse occurred, on 02/06/16 at 9:00 PM, in the Psych Unit. The patient had been discharged from the facility on 02/10/16.

Interview with the Chief Medical Officer during the above meeting revealed he was informed of the violent incident between Patient #1 and the staff; however, what was reported to him was the patient had struck and injured the staff and had sustained injury during that altercation. He stated he was notified for medical advice and he instructed the House Manager to obtained medical treatment for the staff and the patient. He stated abuse was not reported to him and it was not reported Security Officer #1 or RN #2 had hit the patient. He was unaware of the allegation until the Director of Risk Management informed him on Monday, 02/08/16.

Interview with the Director of the Psychiatric Unit, on 2/17/16 at 1:21 PM, revealed she was not working the night of the incident. She stated she received a text from the Unit Manager stating there was an incident of assault on the unit. She stated two nurses were working the night of the incident, but RN #1 was the patient's primary nurse. She stated the doors to the seclusion room were locked. It was reported to her RN #1 had observed the patient standing up on the bed on the monitors at the Nurses' Station. The nurse then went to assess the situation. Review of the Director's phone text revealed she received the text from the Unit Manager at 10:27 PM on 02/06/16. Review of the text revealed a report of an assault on the unit and that she would discuss the matter on Monday, 02/08/16. The Director stated she met with the Unit Manager on 02/08/16 to discuss the incident. The Unit Manager told the Director she had written statements from the staff. She spoke with the Chief Nursing Officer (CNO) on Monday (02/08/16) and filled her in on the details. She met with the Director of Risk Management on Tuesday regarding the concerns about this case.

Interview with Security Officer #2, on 02/17/16 at 3:01 PM, revealed he had been rehired to work at the facility a little over a year ago. He stated the night of the incident he escorted the patient from the ED to the Psych Unit. He stated it was the facility's policy to have two security officers to escort a patient to the Psych Unit. He stated the patient was put into the seclusion room. The patient cooperated with the nurse when she assessed the patient and gave him/her medication. He stated the nurses left and went to the Nurses' Station and the seclusion room door was locked. Security Officer #1 had walked to the Nurses' station to get the wand to detect metal. The Security Officers used the device to search for knives and other sharp devices. The officer found none. The patient was dressed in paper scrubs with the patient's street clothing removed in the ED per protocol. Once the patient had been searched, the nurses left and he went into the Ante room (small entrance room outside the seclusion room). Security Officer #1 was the last one to leave the seclusion room. When this officer left the room, the patient was laying on the bed not speaking. Very quickly the patient jump up on top of the bed and said, "You come here." He was pointing to Security Officer #1. The patient started ripping of the paper top and Security Officer #1 told the patient he/she didn't have to take off the top. The patient then said, "You are not going anywhere". Security Officer #1 pushed the patient off the bed to the wall. The patient began swinging and trying to hit the officer. He went back into the seclusion room and observed Security Officer #1 fall onto the floor with the patient on top of him. The patient was hitting the Officer #1 on the head. He pulled the patient off the other officer and the patient started hitting him in the face. The patient hit Security Officer #2 in the lip and jaw twice. He pushed the patient off him and at the same time RN #2 came back into the room and the patient went after him. The patient ran from the Seclusion Room into the Ante room. By that time, Security Officer #1 was back on his feet and went after the patient. He pushed the patient into a corner of the Ante room and placed his body over the patient's to hold him/her down. He called a Code Man, but before the team could arrive to help, he observed Security Officer #1 place the patient into a head lock and punch the patient in the face with his fist. He heard Security Officer #1 tell RN #2 to hit the patient in the face and he did. The patient began bleeding from the face. He stated he didn't say anything about what he saw at that time. Then RN #1 came to the door and brought restraints. However, there were only three (3) restraints and they needed four (4). He left the room to search for another limb restraint. The Code Man team had responded by that time. When he returned with the fourth restraint, the patient was on the bed in the seclusion room, cooperative, bleeding from the face. The patient refused treatment for the injuries at that time so the staff locked the door and left the patient. He did not know if what he saw was abuse or not. He had not reported it as abuse. He could not recall if he had training on abuse. He should have reported the abuse to the Security Manager. He recalled Security Officer #1 worked the next day. He stated he had no training in CSM techniques.

Review of Security Officer #2's written statement revealed the same details the officer stated in his interview. He wrote he had witnessed Security Officer #1 place Patient #1 in a head hold and punched the patient in the face with his fist several times. He also wrote he witnessed RN #2 hit the patient in the face with his fist.

Interview with RN #1, on 02/17/16 at 3:35 PM, revealed she was Patient #1's nurse the night of the alleged abuse. She stated she received report from the ED nurse that the patient was quiet in the ED, but attempted to leave. Once on the unit, she assessed the patient in the Seclusion Room and the patient appeared to be anxious. She stated the patient was delusional calling her the devil and the patient could not follow directions. She obtained an order and administered medications to calm the patient. The patient refused the medication at first but then agreed to take the medications. She took the patient's vital signs and performed a physical assessment. The patient was sitting up on the bed, looking around like he was paranoid. She then left the Seclusion Room and went back to the Nurses' Station. The Security Officers were left with the patient. She stated she heard a commotion and looked at the monitors and saw Patient #1 standing up on the bed. She then saw a struggle between Security Officer #1 and the patient, and then they went out of the camera's frame. She immediately went to the Seclusion Room. When she pushed the Ante Room door opened she saw the patient on the floor with Security Officer #1's body on top of him holding the patient down. The two Security Officers and RN #2 were in the small room with the patient. She witnessed Security Officer #1 hit the patient in the face with a closed fist several times. She told him to stop because they could not do that. The other officer (#2) touched Security Officer #1's hand and said, "Stop Man" and the officer finally stopped. She did not see RN #2 hit the patient, but she was not present the whole time. She told the House Manager what she had witnessed. He told Security Officer #1 to get treatment and then go home. The patient had a laceration to the forehead. A medical consult was obtained with order for a Computerized Tomography (CT) scan. The CT scan revealed the patient had a fracture nose. The patient went to the ED for sutures of the laceration on the forehead. She stated the patient was placed back into the Seclusion Room without any other outburst.

Review of RN #1's written statement revealed the patient was received from the ED, on 02/06/16 at 8:45 PM. The patient was taken to the Seclusion Room. The patient was found to be religiously preoccupied and made statements that the nurse was the devil. The nurse documented she was working on paperwork when she heard a disturbance from the Seclusion Room. She looked at the camera monitor and saw the patient standing on top of the bed and there was a physical struggle between Security Officer #1 and the patient. She went to assess the situation and when she tried to open the door, she could not because Security Officer #2 had his arm against the door. When he moved his arm and she looked inside the door, she saw the patient lying on his back, on the floor, with Security Officer #1's body on top of the patient. She saw Security Officer #1 draw back his closed fist and strike the patient three (3) times in the face. She told him to stop because they could not hit patients. The officer drew back his fist again and then Security Officer #2 asked him to stop and he did. A Code Man was called and the patient was assisted back to the bed in the seclusion room. She noticed a significant amount of blood on the floor. The patient had an area to the forehead and blood on the right shoulder. The House Manager was called to the unit and informed of the incident. The patient was placed in four-point restraints for exam. The patient had a CT completed that was positive for nasal bone fracture. The patient required sutures in the ED for the laceration to the forehead.

Interview with Security Officer #1, on 02/18/16 at 10:00 AM, revealed he had been employed by the facility for over three (3) years. He stated he first saw the patient in the ED wandering around. He assisted the ED staff to apply physical restraints. He stated the patient was not aggressive in the ED. He transported the patient to the Psych Unit with Security Officer #2. The patient had not spoken during the transport. The patient was placed in the seclusion room and requested to sit on the bed. It took several requests, but the resident finally sat on the bed. The patient's eyes were dilated and the patient had a blank angry look on his/her face. Security Officer #2 observed RN #2 give the patient some medications. He said the patient just laid on the bed while he ran the wand over the patient's body to search for metal objects. The officer stated they were leaving the seclusion room when the patient asked him if he would forgive him/her. The patient asked if God would forgive him/her and then said "I don't think he will this time". The patient was still lying on the bed flat. The officer stated there was something in the patient's tone of voice and then his/her face changed to a blank stare. The patient jumped from the bed, and tore off the paper shirt. The officer stated, "What are doing?" He told the patient the search was over. The patient then told the officer, "You are not going anywhere" while he/she was pointing their finger at him. The officer stated he tried to leave the room, but the patient jumped on top of the bed and was coming toward him. He took his left hand and pushed the patient off the bed and he landed on his/her feet. The officer stated he could not recall all the details, but he tried to grab the patient, fell to the floor and the patient was hitting him in the head several times. Security Officer #2 got the patient off the officer and then the patient started hitting him. The patient ran around the bed to get out the door and RN #2 was standing there. The patient hit RN #2. The patient made it into the Ante room. He was on his feet then and tried to grab the patient around the arms. He stated "he didn't have a choice". He put the patient in the floor, corner of the Ante room. He had his right arm around the patient and hit him with his left hand several times. They both went onto the floor. His body covered his/her. He recalled putting the patient in a head lock. He stated his left arm had blood on it, but it was not his, it was the patient's.

Continued interview with Security Officer #1 revealed he had "Zero" training on how to deal with combative or aggressive patients. He stated that was the first time he had encountered an incident like that. He had CSM class when he first started working at the facility three (3) years ago. He did not recall any training on abuse. The officer didn't know how many times he hit the patient. He stated he had no training on CSM holds. He said he feared for his life, he was attached and fought back. The officer stated after the Code Man was called and the team came to assist, he went to the ED for treatment. He stated his manager came in for coverage and requested him to provide a written statement. Security Officer #1 revealed he worked the next day and was on the Psychiatric Unit two times making rounds. He saw the patient in the dayroom, and had no communication with the patient. He stated he was called in to speak with the Risk Management Director on Monday, 02/09/16. He was suspended on 02/10/16. He stated he was only doing his job. He felt like he was not trained and was afraid.

Review of the written statement by Security Officer #1 revealed the officer admitted to pushing the patient off the bed. He documented he struck the patient in the forehead. The officer documented the patient fell down and he laid on top of him with the patient' arms restrained while he waited for the Code Man team. The officer wrote he acted justly and appropriately under the facility's force policy and felt he had handled the difficult situation the best he could. However, interviews with the Administrative staff and review of facility policies revealed there was no force policy the officer referred to.

Interview with RN #2, on 02/18/16 at 11:05 AM, revealed he had only worked in the Psych Unit since August 2015. He revealed he was only helping RN #1 that night because Patient #1 was not assigned to him. When the patient was admitted to the unit he/she was placed in the seclusion room. The patient was delusional calling RN #1 the devil and the patient was Jesus Christ and he/she needed to sacrifice his/her life for their sins and save man-kind. The patient was given medications to calm down. He stated the patient was left alone in the locked seclusion room for a short while. The patient was lying on the bed quietly. The two Security Officers were in the Ante Room just outside the seclusion room.
Security Officer #1 went to the Nurses' Station to get the wand. The nurses and Security Officer #1 walked back to the seclusion room opened the door and everyone went in. The patient was resistive of taking the medication at first, but then took the medication. The patient was calm. RN #1 left the seclusion room first followed by RN #2 and Security Officer #2. Security Officer #1 was in the doorway attempting to leave. The patient yelled at Security Officer #1, "Hey, tall guy, I need to talk to you." RN #2 turned and heard the patient say he/she was sorry for his/her behavior in the ED. Security Officer #1 told the patient he/she didn't do anything wrong by him. All of a sudden, the patient stood up on the bed and took off his/her scrub top. Security Officer #1 told the patient they didn't do those types of searches. The patient then lunged at the officer and the officer pushed back. Security Officer #1 lost his balance and fell to the floor. The patient jumped on top of him and started hitting the officer in the head. The nurse stated everything happened so fast and then Security Officer #2 came into the seclusion room and got the patient off Security Officer #1. The patient started hitting Security Officer #2. Then the patient charged at RN #2 and hit him in the face. The officers had time to recover and pushed the patient into the Ante room. Patient #1 was still on his/her feet at that time. Officer #1 was trying to hold the patient, but the patient was swinging his/her arms uncontrollably. Officer #1 got behind the patient and told the nurse to hit the patient. RN #2 stated he put his arm out and made contact with the patient's face. The patient and Officer #1 fell onto the floor of the Ante Room. The officer took the patient down. The officer had his body over the patient's and yelled to call a Code Man and Police. That is when the patient said, "I'm done", "I'm done." The nurse stated he looked at the patient and Officer #1 and the patient was not fighting and was not bleeding. He stated he was rubbing his jaw where he had been hit when RN #1 opened the door to the Ante Room and yelled. "You all can't do that." He looked up and saw Security Officer #1 hitting the patient in the face with his closed fist. Officer #2 yelled at that officer, "Man stop", "Man stop." That is when RN #2 saw blood coming from the patient's face. This nurse denied he hit the patient with his fist or opened hand when the patient stated he/she was done.

Continued interview with RN #2 revealed he had never encountered a situation like that before and he was afraid. He stated there was no time to de-escalate the situation. He stated he had CSM training and he thought they went over a few specific holds, but he froze when t

Based on interviews, record review, and review of the facility's policies and documents, it was determined the facility failed to protect and promote patient rights, prevent physical abuse, and provide care in a safe setting for one (1) of twelve (12) sampled patients. Patient #1 was admitted to the Psychiatric Unit and placed in a closed seclusion room on 02/06/16 after evaluation in the Emergency Department (ED). The patient was brought to the ED by the police due to the patient having been found wandering in the street, barefoot, and acting incoherent. The ED listed the chief complaint to be the patient was delusional with hallucinations. A drug screen was performed and the patient tested positive for amphetamine and marijuana (THC). A seventy-two (72) hour hold was obtained for treatment. Once the patient was admitted to the Psychiatric Unit, the patient became aggressive and violent with the staff. The patient attacked two Security Officers and a nurse. During the altercation, Security Officer #1 and Registered Nurse (RN) #2 was witnessed to strike the patient in the face several times with a closed fist. The patient sustained a fractured nose and laceration to the forehead that required sutures.

In addition, the facility failed to implement appropriate Crisis Situation Management (CSM) techniques and found the staff involved in the altercation with Patient #1 had not been properly trained. The Security Officers had not received abuse training and review of the abuse training provided to the nurses revealed employee to patient abuse was not discussed. Interviews with staff revealed the alleged physical abuse was reported to the House Manager and written statements were obtained. However, the manager failed to report the alleged abuse to the Administrative On-Call person and the facility did not report the alleged abuse to the Department of Community Based Services (DCBS) until 02/10/16, four (4) days after the alleged abuse occurred. Security Officer #1 and RN #2 were allowed to work after the alleged abuse and were in contact with the patient.

The facility's failure to ensure Patient #1 received care in a safe setting, ensure patients were not abused, to train staff on CSM and abuse reporting, and failure to report the alleged abuse and implement corrective actions placed Patient #1 and all patients in the facility at risk for serious injury, harm, impairment or death.

Refer to A 0144 and A 0145

Based on observation, interviews, record review, and review of the facility's policies and documents, it was determined the facility failed to protect and promote patient rights and provide care in a safe setting for one (1) of twelve (12) sampled patients. Patient #1 was admitted to the Psychiatric Unit under an involuntary seventy-two (72) hour hold for close monitoring of drug induced Psychosis on 02/06/16. Staff interviews and nursing assessments revealed the patient was religiously preoccupied and in a agitated state. The patient was placed in a locked seclusion room with two Security Officers and two nurses in attendance. The patient was given medication to help calm them down. The patient became aggressive toward Security Officer #1 and then attacked the officer. There was a struggle with the patient. During the struggle the Security Officers and the patient were brought down to the floor. It was witnessed that Security Officer #1 placed the patient in a head lock and hit the patient in the face several times with his closed fist. The patient sustained a fracture nose and laceration to the forehead that required sutures in the ED.

The facility staff reported the alleged physical abuse to the House Manager who failed to investigate the allegation or report the allegation until 02/08/16. The facility failed to report the alleged abuse to the State Agency until 02/10/16, four days after the alleged abuse occurred. Security Officer #1 and Registered Nurse (RN) #2 were allowed to work with the patient after the alleged abuse was witnessed.

The facility identified the event to be a serious safety event and the investigation was still ongoing during the survey. The facility identified a root cause analysis that staff were not properly trained, the abuse policy was not clear regarding reporting, and corrective actions had not been implemented.

The findings include:

Review of the facility's Abuse Policy, revised on 08/20/14 and 11/18/14, revealed the purpose of the Abuse Policy was to protect patient's rights to be free from abuse and to establish appropriate procedures for responding to reports of abuse, neglect, or exploitation. The policy stated the patient had a right to be free from verbal, physical, mental, or other abuse, including neglect and exploitation. Such abuse would not be tolerated from any employee, volunteer, student, physician, patient, visitor, or other individual. Under the definition of physical abuse included but not limited to, hitting, slapping, punching and kicking. Physical abuse also included controlling a patient's behavior through corporal punishment. Allegations made against a facility employee must be reported by the first person becoming aware of the allegation. That person would notify the Department/Unit Manager or House Manager who would ensure that immediate measures necessary were taken for patient safety, and then notify the following persons: Department Director, Vice President, Administrator On-Call, Attending Physician, Director of Risk Management, and Social Services (who report the allegation to the Department of Protection and Permanency as appropriate.) The Department/Unit Manager or House Manager would obtain a detailed statement from the patient/family member making the allegation. There was nothing in the policy to direct staff on what to do if they had observed an employee abuse a patient. The policy stated generally, an employee would be suspended pending further investigation of allegations of patient abuse.

Another portion of the abuse policy, revised on 11/18/14, list references for the abuse policy to be KRS 209.30 Administrative regulations-Reports of adult abuse, neglect, or exploitation.

Review of the Abuse Policy specific to the Psychiatric Unit, revision date of 10/26/15, revealed this policy applied to all trained care providers and Psychiatric Unit staff. The procedure stated nursing would complete an assessment of patient's reports of abuse. Nursing would document all available information in the medical record including nature of the reported abuse, time it occurred, and injuries received. Nursing would inform the Social Worker and if unable to reach, leave a message. The Social Worker evaluates the patient's report, makes referral, and documents the referral. A reporting form was attached to this policy that was designed for abuse allegations which occurred outside the facility such as domestic violence and not for employee to patient abuse.

Review of the DCBS tracking ID intake form revealed the facility notified the state agency of the allegation of physical abuse on 02/10/16 at 3:35 PM, four days after the alleged abuse had occurred.

Review of the Patient's Rights for Protective Service Policy, reviewed 06/30/14 and revised May 2012, revealed the purpose of the policy was to provide patients information/services necessary to ensure their protection related to Abuse/Neglect and Exploitation. The policy referenced KRS 209.30.

Review of the Assault or Violent Behavior Policy, revised 10/26/15, revealed the policy was created specific for the Psychiatric Unit. The purpose was to ensure nursing was knowledgeable of behavior indicating potentially dangerous situations. The policy applied to all trained care providers, Psychiatric Unit staff, and Security Department staff. Stage I of the policy instructed staff to be alert to patients posing a higher risk of violent behaviors that included paranoia, inability to concentrate, increased voice volume, substance withdrawal, and psychosis-auditory or visual hallucinations. The key point was to notify the physician of escalating behaviors. Stage II was to call a "Code Man." Staff members participating in a "Code Man" are well trained in body mechanics and methods of holding a struggling patient without causing injury; Maintaining a comfortable distance (beyond the reach of hands/feet) from the patient; Facing the patient and maintaining an exit at your back; Only one person should talk with the patient; A staff member would be assigned to restrain each limb. When a patient's out of control state is acknowledged, tell the patient the staff are prepared to maintain control of him/her until they regain self-control. Tell the patient what you want them to do. Use the least amount of force necessary. Try to appear calm and in control. Do not show anger. If physical restraints are used, move without hesitation in an organized manner restraining all limbs. Explain to the patient that control was being maintained for them until self-control could be restored. Document clearly the mental status of the patient and threat of danger posed for themselves or others. Document interventions attempted to decelerate patient, but were unsuccessful. If there were injury to the patient, staffs, or visitor, fill out an incident report.

Review of the facility's Code Man Policy, revised March 2011, revealed the purpose of the policy was to recruit assistance in preventing a non-armed, agitated, confused, and/or combative person from causing injury to self or others. Crisis Situation Management (CSM) training was provided for responders from the Security Department, Emergency Department, Plant Engineering Department, and designated staff from Environmental Services. Staff responding from other departments (Nursing and Transport) respond for manpower purposes (i.e. assist with physical control of combative person) under direct supervision of CSM trained personnel. Available Security personnel and trained CSM personnel respond to the announced location as quickly and safely as possible. If the situation is determined to be a medical crisis, nursing staff direct the actions of the responders, if the situation becomes threatening to staff, Security directs the action of the responders. In the event injury occurred to the patient, staff, or visitor, a reportable event form was to be completed. Employees are sent to the ED or Employee Health.

Review of the facility's Patient Rights and Responsibility Policy, revised date of March 2012 and review date of 04/23/14, revealed the purpose of the policy was to inform, promote, and protect the basic rights of the patients to treatment, care, and services within the facility's capability and mission in compliance with applicable laws and regulations. The policy stated the patient had the right to receive fair compassionate care at all times and under all circumstances. The patient had the right to receive care in a safe setting, to be free from abuse and harassment, and have access to protective services as needed.

Record Review of Patient #1's clinical record revealed the patient was brought to the Emergency Department (ED), on 02/06/16 at 4:41 PM via the police. According to the ED physician's clinical report, the police had found the patient wandering in the street barefoot and acting incoherent. The patient was making statements about being Jesus and exhibited unusual behavior. The chief complaint listed was withdrawn, delusional and hallucinations. This had started the night before. The physician documented the patient's symptoms were described as severe. A drug screen was performed and the patient tested positive for amphetamine and marijuana (THC).

Review of the History and Physical, dated 02/07/16, revealed the patient was admitted to the Psych Unit on a seventy-two (72) hour hold when in the ED the patient was noted to be psychotic, very paranoid and attempted to leave the ED. Upon admission to the Psych Unit, the patient appeared to be very apprehensive. The physician ordered medication that included Haldol, Benadryl and Ativan. The patient accepted the medications. Suddenly, the patient became agitated and aggressive and began kicking, punching, and fighting the security officers. During this encounter, the patient was injured, that included forehead laceration and nose bleed. A Computerized Tomography (CT) scan revealed the patient sustained a nose fracture of the right nasal bone and required sutures for the laceration to the forehead. The attending physician interviewed the patient the next day (02/07/16) and the patient said he/she remembered bits and pieces of what happened to him/her. The patient told the physician he/she experienced visual and auditory hallucinations and felt very scared and apprehensive. The physician documented the patient's insight, judgment, and impulse control were significantly impaired. Diagnostic impression was severe drug use of amphetamine and marijuana and substance-induced psychosis.

Review of the Hospitalist Consult documentation (on 02/07/16) to evaluate Patient #1's injuries after the altercation with the security officers, revealed jagged laceration to the forehead with edema and tenderness. In addition, the nasal bones were assessed to be swollen into the bilateral super maxillary soft tissue. Contusions were noted on the left mid-calf and right posterior elbow. The Hospitalist documented the patient had multiple abrasions and contusions. He requested the patient's laceration to the forehead be treated in the ED.
Review of the ED records revealed physical restraints were applied on 02/06/16 at 6:10 PM, due to the patient bolting out of the ED room. The local police were in the ED (for another reason) and assisted the patient back to the ED bed. The reason for the physical restraints was the patient exhibited violent behavior including imminent risk of harm to self or others. Four-point restraints were applied. The one hour face to face restraint assessment was performed at 7:55 PM and documented the patient was agitated and confused.

Review of the nursing admission note, dated 02/06/16, revealed Patient #1 was admitted to the Psychiatric Unit at 8:45 PM for an involuntary seventy-two (72) hour hold with a diagnosis of Drug Induced Psychosis. Report from the ED nurse stated the patient had a history of Psychosis and Substance Abuse. The nurse reported the patient's eyes were dilated and the drug screen test was positive for amphetamine and marijuana. The nurse documented the patient had bolted out of the exam room, but was returned and placed in physical restraints. The patient arrived on the Psychiatric Unit in a wheelchair accompanied by two Security Officers. The patient was taken to the Seclusion Room for assessment. The patient initially resisted moving from the wheelchair to the bed but did with several directions and reassurance from staff. The patient was religiously preoccupied stating the nurse was the devil and asked that staff kill him/her because he/she needed to die for them. Due to the patient's psychotic agitated state, medication was ordered and admistered. The patient was given Haldol 5 mg (1), Benadryl 50mg (1), and Ativan 2 mg (1) via mouth. The patient took the medication with some hesitation at 9:50 PM. The patient was placed in seclusion due to the agitation and psychosis. The nurse left the seclusion room, then returned to perform vital signs and a physical assessment. The door to the Seclusion Room had been locked with both Security Officers present in the Transition (Ante) Room. The patient was cooperative at that time. RN #1 returned to the nurses' station leaving RN #2 and the two Security Officers in the seclusion room with the patient. While at the nurses' station, RN #1 saw the patient stand up on the bed from the monitors at the Nurses' Station. The nurse documented she went to the Seclusion Room to assess the situation. She found one Security Officer struggling with the patient on the floor. A Code Man was called due to out of control and aggressive behaviors. The patient was placed back into seclusion with one to one staff monitoring.

On 02/17/16 at 12:36 PM, a meeting was held with the following facility Administrative staff: Chief Executive Officer, Director of Compliance, Vice President; Chief Nursing Officer; Director of Risk Management; Director of Quality Management; and the Chief Medical Officer. The Director of Risk Management conducted the facility's internal investigation of the alleged physical abuse. He stated he learned of the alleged abuse on 02/08/16 after reading written statements from facility staff working the night of the alleged abuse. He stated he immediately set up interviews with all staff involved. He stated after those interviews was the first time there was an indication of abuse. He stated the interviews with RN #1 and Security Officer #2, on 02/09/16, revealed they had witnessed the alleged abuse and he learned Patient #1 had sustained injury. On 02/10/16, the Administrative staff determined the need to report the alleged abuse to the State Agency - DCBS.

The Director of Risk Management stated a report given to him revealed the patient had become extremely violent and had injured two Security Officers and RN #2. The report revealed the patient had sustained injury, but indicated the injuries were sustained during the struggle with staff. The report stated the patient had been struck in the act of trying to restrain the patient. The report stated it took three (3) big men to contain the patient. The House Manager voiced concern about the patient getting out of hand again. The patient was seen by a Hospitalist to assess the patient's injuries. The Hospitalist ordered a CT scan that revealed a nasal fracture and ordered for the patient to be seen in the ED for the laceration to the forehead that required sutures. A psychiatric consult was ordered for a possible transfer to another psychiatric hospital. The Risk Manager stated RN #1 reported what she witnessed to the House Manager and he informed the Administrator On-Call (Chief Medical Officer). The alleged abuse occurred on 02/06/16 at 9:00 PM in the Psych Unit. The patient had been discharged from the facility on 02/10/16.

Interview with the Chief Medical Officer during the above meeting revealed he was informed of the violent incident between Patient #1 and the staff; however, what was reported to him was the patient had struck and injured the staff and had sustained injury during that altercation. He stated he was notified for medical advice and he instructed the House Manager to obtained medical treatment for the staff and the patient. He stated abuse was not reported to him and it was not reported that Security Officer #1 or RN #2 had hit the patient. He was unaware of the allegation until the Director of Risk Management informed him on Monday, 02/08/16.

Interview with the Director of the Psychiatric Unit, on 2/17/16 at 1:21 PM, revealed she was not working the night of the incident. She received a text from the Psych Unit Manager stating there was an incident of assault on the unit. She stated there was a camera in the seclusion room, it did not record, but was on the monitor at the Nurses' station. She stated two nurses were working the night of the incident, but RN #1 was the patient's primary nurse. The doors to the seclusion room were locked. It was reported to her RN #1 had observed the patient standing up on the bed on the monitors at the Nurses' station. The nurse then went to assess the situation. Review of the Director's phone text revealed she received the text from the Unit Manager at 10:27 PM on 02/06/16. Review of the text revealed a report of an assault on the unit and that she would discuss the matter on Monday, 02/08/16. The Director stated she met with the Unit Manager on 02/08/16 to discuss the incident. The Unit Manager told the Director she had written statements from the staff. She spoke with the Chief Nursing Officer (CNO) on Monday (02/08/16) and filled her in on the details. She met with the Director of Risk Management on Tuesday regarding the concerns about this case.

Interview with Security Officer #2, on 02/17/16 at 3:01 PM, revealed he had been rehired to work at the facility a little over a year ago. He stated the night of the incident he escorted the patient from the ED to the Psych Unit. He stated it was the facility's policy to have two security officers to escort a patient to the Psych Unit. He stated the patient was put into the seclusion room. The patient cooperated with the nurse when she assessed the patient and gave him/her medication. He stated the nurses left and went to the Nurses' station and the seclusion room door was locked. Security Officer #1 had walked to the Nurses' station to get the wand to detect metal. The Security Officers use the device to search for knives and other sharp devices. The officer found none. The patient was dressed in paper scrubs with the patient's street clothing removed in the ED per protocol. Once the patient had been searched, the nurses left and he went into the Ante room (small entrance room before entrance to the isolation room). That left Security Officer #1 alone in the seclusion room with the patient. When he left the room, the patient was laying on the bed not speaking. Very quickly the patient jumped up on top of the bed and said, "You come here." He was pointing to Security Officer #1. The patient started ripping off the paper top and Security Officer #1 told the patient he didn't have to take off his/her shirt. The patient then said, "You are not going anywhere." The patient was standing on the bed. Security Officer #1 pushed the patient off the bed to the wall. The patient began swinging his fists and trying to hit the officer. Security Guard #2 went back into the seclusion room and observed Security Officer #1 fall onto the floor with the patient on top of him. The patient was hitting Officer #1 on the head. Security Officer #2 stated he picked the patient off the other officer and the patient started hitting him in the face. The patient hit Security Officer #2 in the lip and jaw twice. He stated he pushed the patient off him and at the same time RN #2 came back into the room and the patient went after the RN. The patient ran from the seclusion room into the Ante room. By that time, Security Officer #1 was back on his feet and went after the patient. He pushed the patient into a corner of the Ante room and placed his body over the patient's to hold him/her down. He called a "Code Man", but before the team could arrive to help, Security Officer #1 placed the patient into a head lock and punched the patient in the face with his fist. The officer then told RN #2 to hit the patient in the face and he did. The patient began bleeding from the face. He stated he didn't say anything about what he saw at that time. Then RN #1 came to the door and brought restraints. However, there were only three (3) restraints and they needed four (4). He left the room to search for another limb restraint. The Code Man team had responded by that time. When he returned with the fourth restraint, the patient was on the bed in the seclusion room, cooperative, bleeding from the face. The patient refused treatment for the injuries at that time so the staff locked the door and left the patient. He did not know if what he saw was abuse or not. He had not reported it as abuse. He had received training on abuse, but could not recall when. He stated he should have reported the abuse to the Security Manager. He recalled Security Officer #1 worked the next day and he stated he had no training in CSM techniques.

Review of Security Officer #2's written statement revealed the same details the officer stated in his interview. He had witnessed Security Officer #1 place Patient #1 in a head hold and punched the patient in the face with his fist several times. He also wrote he witnessed RN #2 hit the patient in the face with his fist.

Interview with RN #1, on 02/17/16 at 3:35 PM, revealed she was Patient #1's nurse the night of the alleged abuse. She stated she received report from the ED nurse that the patient was quiet in the ED, but attempted to leave. Once on the unit, she assessed the patient in the seclusion room and the patient appeared to be anxious. She stated the patient was delusional calling her the devil and the patient could not follow directions. She stated she obtained orders and administered medications to calm the patient. The patient refused the medication when first offered, but then agreed to take the medications. She took the patient's vital signs and performed a physical assessment. She stated the patient was sitting up on the bed, looking around like he was paranoid. She then left the seclusion room and went back to the nurses' station. The Security Officers were left with the patient. She stated she heard a commotion and looked at the monitors and saw Patient #1 standing up on the bed. She then saw a struggle between Security Officer #1 and the patient, and then they went out of the camera's frame. She immediately went to the seclusion room and when she pushed the door to the entrance of the Ante room, she saw the patient on the floor with Security Officer #1's body on top of him holding the patient down. She stated the two Security Officers and RN #2 were in the small room with the patient. She stated she witnessed Security Officer #1 hit the patient in the face with a closed fist several times. She told him they could not do that. The other officer (#2) touched Security Officer #1's hand and said, "Stop Man" and the officer finally stopped. She did not see RN #2 hit the patient but, she was not present the whole time. She stated she told the House Manager what she had witnessed when the manager responded to the Code Man. He told Security Officer #1 to get treatment and then go home. The patient had a laceration to the forehead. A medical consult and the CT scan revealed the patient had a fractured nose. The patient was placed back into the seclusion room without any other outburst.

Review of RN #1's written statement revealed the patient was received from the ED on 02/06/16 at 8:45 PM. The patient was taken to the seclusion room. The patient was found to be religiously preoccupied and made statements that the nurse was the devil. The nurse documented she was working on paperwork when she heard a disturbance from the Seclusion Room. She looked at the camera monitor and saw the patient standing on top of the bed and there was a physical struggle between Security Officer #1 and the patient. She went to assess the situation and when she tried to open the door, she could not because Security Officer #2 had his arm against the door. When he moved his arm and she looked inside the door, she saw the patient lying on his back, on the floor, with Security Officer #1's body on top of the patient. She saw Security Officer #1 draw back his closed fist and struck the patient three (3) times in the face. She told him to stop because they could not hit patients. The officer drew back his fist again and then Security Officer #2 asked him to stop and he did. A Code Man was called and the patient was assisted back to the bed in the seclusion room. She noticed a significant amount of blood on the floor. The patient had an area to the forehead and blood on the right shoulder. The House Manager was called to the unit and informed of the incident. The patient was placed in four-point restraints for exam. The patient had a CT completed that was positive for nasal bone fracture. The patient required sutures in the ED for the laceration to the forehead.

Interview with Security Officer #1, on 02/18/16 at 10:00 AM, revealed he had been employed by the facility for over three (3) years. He stated he first saw the patient in the ED wandering around. He assisted the ED staff to apply physical restraints. The patient was not aggressive in the ED. He transported the patient to the Psych Unit with Security Officer #2. The patient had not spoken during the transport. The patient was placed in the seclusion room and requested to sit on the bed. It took several requests but the resident finally sat on the bed. The patient's eyes were dilated and the patient had a blank angry look on his/her face. Securtiy Officer #1 observed RN #1 give the patient some medications. He said the patient just laid on the bed while he ran the wand over the patient's body to search for metal objects. They were leaving the seclusion room when the patient asked him if he would forgive him/her. The patient asked if God would forgive him/her and then said "I don't think he will this time." The patient was still lying on the bed flat. The officer stated there was something in the patient's tone of voice and then his/her face changed to a blank stare. The patient jumped from the bed, and tore off the paper shirt. The officer stated, "What are doing?" I told the patient the search was over. The patient then told the officer, "You are not going anywhere", while the patient was pointing their finger at him. The officer stated he tried to leave the room, but the patient jumped on top of the bed and was coming toward him. He took his left hand and pushed the patient off the bed and he/she landed on his/her feet. The officer stated he could not recall all the details, but he tried to grab the patient, fell to the floor and the patient was hitting him in the head several times. Security Officer #2 got the patient off the officer and then the patient started hitting him. The patient ran around the bed to get out the door and RN #2 was standing there. The patient hit RN #2. The patient made it into the Ante room. He was on his feet then and tried to grab the patient around the arms. Security Officer #1 stated "He didn't have a choice". He put the patient in the floor, in the corner of the Ante room. He had his right arm around the patient and hit him/her with his left hand several times. They both went onto the floor. His body covered the patient. He recalled putting the patient in a head lock. He stated his left arm had blood on it, but it was not his, it was the patient's.

Continued interview with Security Officer #1 revealed he had "Zero" training on how to deal with combative or aggressive patients. He stated that was the first time he had encountered an incident like that. He stated he had CSM class when he first started working at the facility three (3) years ago. He did not recall any training on abuse. The officer didn't know how many times he had hit the patient. He had no training on SCM holds. He said he feared for his life, he was attacked and fought back. The officer stated after the Code Man was called and the team came to assist, he went to the ED for treatment. He stated his manager came in for coverage and requested him to provide a written statement. Security Officer #1 worked the next day and was on the Psych Unit two times making rounds. He saw the patient in the dayroom, but reported no communication between them. He stated he was called in to speak with the Risk Management Director on Monday, 02/09/16. He was suspended on 02/10/16. He stated he was only doing his job. He felt like he was not trained and was afraid.

Review of the written statement by Security Officer #1 revealed the officer admitted to pushing the patient off the bed. He documented he struck the patient in the forehead. The officer documented the patient fell down and laid on top of him with the patient' arms restrained while he waited for the Code Man team. The officer wrote he acted justly and appropriately under the facility's force policy and felt he had handled the difficult situation the best he could. However, interviews with the Administrative staff and review of facility policies revealed there was no force policy the officer referred to.

Interview with RN #2, on 02/18/16 at 11:05 AM, revealed he had only worked in the Psych Unit since August 2015. He was only helping RN #1 that night because Patient #1 was not assigned to him. When the patient was admitted to the unit he/she was placed in the seclusion room. The patient was delusional calling RN #1 the devil and the patient was Jesus Christ and he/she needed to sacrifice his/her life for their sins and save man-kind. The patient was given medications to calm down. He stated the patient was left alone in the locked seclusion room for a short while. The patient was lying on the bed quietly. The two Security Officers were in the Ante Room just outside the seclusion room. Security Officer #1 went to the Nurses' Station to get the wand. The nurses and Security Officer #1 walked back to the seclusion room opened the door and everyone went in. The patient was resistive taking the medication at first, but then took the medication. The patient was calm. RN #1 left the seclusion room first followed by RN #2 and Security Officer #2. Security Officer #1 was in the doorway attempting to leave. The patient yelled at Security Officer #1, "Hey, tall guy, I need to talk to you." He turned and heard the patient say he/she was sorry for his/her behavior in the ED. Security Officer #1 told the patient he/she didn't do anything wrong by him. All of a sudden, the patient stood up on the bed and took off his/her scrub top. Security Officer #1 told the patient we didn't do those types of searches. The patient then lunged at the officer and the officer pushed back. Security Officer #1 lost his balance and fell to the floor. The patient jumped on top of him and started hitting the officer in the head. RN #2 stated everything happened so fast and then Security Officer #2 came into the seclusion room and got the patient off Security Officer #1. The patient started hitting Security Officer #2. Then the patient charged at RN #2 and hit him in the face. The officers had time to recover and pushed the patient into the Ante room. Patient #1 was still on his/her feet at that time. Officer #1 was trying to hold the patient, but the patient was swinging his/her arms uncontrollably. Officer #1 got behind the patient and told the nurse to hit the patient. RN #2 stated he put his arm out and made contact with the patient's face. The patient and Officer #1 fell onto the floor of the Ante Room. The officer took the patient down. The officer had his body over the patient's and yelled to call a Code Man and Police. That is when the patient said, "I'm done", "I'm done." The nurse stated he looked at the patient and Officer #1 and the patient was not fighting and was not bleeding. He stated he was rubbing his jaw where he had been hit when RN #1 opened the door to the Ante Room and yelled. "You all can't do that." He looked up and saw Security Officer #1 hitting the patient in the face with his closed fist. Officer #2 yelled at that officer, "Man stop", "Man stop." That was when RN #2 saw blood coming from the patient's face. This nurse denied he hit the patient with his fist or opened hand when the patient stated he/she was done.

Continued

Based on observation, interviews, record review, and review of the facility's policies and documents, it was determined the facility failed to ensure patients were free from abuse for one (1) of twelve (12) sampled patients. Patient #1 was admitted to the Psychiatric Unit for an involuntary seventy-two (72) hour hold for close monitoring of drug induced Psychosis on 02/06/16. Staff interviews and nursing assessments revealed the patient was religiously preoccupied and in an agitated state. The patient was placed in a locked seclusion room and given medication to help calm the patient. The patient became aggressive toward Security Officer #1 and then attacked the officer. There was a struggle with the patient. During the struggle two Security Officers and the patient was brought down to the floor. It was witnessed that Security Officer #1 placed the patient in a head lock and hit the patient in the face several times with his closed fist. The patient sustained a fracture nose and laceration to the forehead that required sutures in the Emergency Department (ED). In addition, Registered Nurse (RN) #2 was witnessed to hit the patient in the face during the altercation with the patient. RN #1 reported the alleged physical abuse to the House Manager on 02/06/16; however, he failed to investigate the allegation or report the allegation to Administrative staff according to the facility's Abuse Policy until 02/08/16. The facility failed to report the alleged abuse to the State Agency until 02/10/16, four days after the alleged abuse occurred. Security Officer #1 and Registered Nurse (RN) #2 were allowed to work with the patient after the alleged abuse had occurred.


The findings include:

Review of the facility's Abuse Policy, revised date of 08/20/14 and 11/18/14, revealed the purpose of the Abuse Policy was to protect patient's rights to be free from abuse and to establish appropriate procedures for responding to reports of abuse, neglect, or exploitation. The policy stated the patient had a right to be free from verbal, physical, mental, or other abuse, including neglect and exploitation. Such abuse would not be tolerated from any employee, volunteer, student, physician, patient, visitor, or other individual. Under the definition of physical abuse included but not limited to, hitting, slapping, punching and kicking. Physical abuse also included controlling a patient's behavior through corporal punishment. Allegations made against a facility employee must be reported by the first person becoming aware of the allegation. That person would notify the Department/Unit Manager or House Manager who would ensure that immediate measures necessary are taken for patient safety, and then notify the following persons: Department Director; Vice President; Administrator On-Call; Attending Physician; Director of Risk Management; and Social Services (who report the allegation to the Department of Protection and Permanency as appropriate). The Department/Unit Manager or House Manager would obtain a detailed statement from the patient/family member making the allegation. There was nothing in the policy to direct staff on what to do if they observed an employee abuse a patient. The policy stated generally, an employee was suspended pending further investigation of allegations of patient abuse.

Review of the Abuse Policy specific to the Psychiatric Unit, revised date 10/26/15, revealed this policy applied to all trained care providers and Psychiatric Unit staff. The procedure stated nursing would complete assessment of patient's report of abuse. Nursing would document all available information in the medical record including nature of the reported abuse, time it occurred, and injuries received. Nursing would inform the Social Worker and if unable to reach, leave a message. The Social Worker evaluates the patient's report, makes referrals, and documents the referral. A reporting form was attached to this policy that was designed for abuse allegations which occurred outside the facility such as domestic violence and not for employee to patient abuse.

Review of the Department for Community Based Services (DCBS) tracking ID intake form revealed the facility notified the state agency of the allegation of physical abuse, on 02/10/16 at 3:35 PM, four days after the alleged abuse had occurred.

Review of the Patient's Rights for Protective Service Policy, reviewed 06/30/14 and revised May 2012, revealed the purpose of the policy was to provide patients information/services necessary to ensure their protection related to Abuse/Neglect and Exploitation. The policy referenced KRS 209.30.

Review of the Assault or Violent Behavior Policy, revised 10/26/15, revealed the policy was created specific for the Psychiatric Unit. The purpose was to ensure nursing was knowledgeable of behavior indicating potentially dangerous situations. The policy applied to all trained care providers, Psychiatric Unit staff, and Security Department staff. Stage I of the policy instructed staff to be alert to patients posing a higher risk of violent behaviors that included paranoia, inability to concentrate, increased voice volume, substance withdrawal, and psychosis-auditory or visual hallucinations. The key point was to notify the physician of escalating behaviors. Stage II was to call a "Code Man". Staff members participating in a "Code Man" are well trained in body mechanics and methods of holding a struggling patient without causing injury; maintaining a comfortable distance (beyond the reach of hands/feet) from the patient; face the patient and maintain an exit at your back; only one person should talk with the patient; a staff member would be assigned to restrain each limb. When a patient's out of control state is acknowledged, tell the patient the staff are prepared to maintain control of him/her until they regain self-control. Tell the patient what you want them to do. Use the least amount of force necessary. Try to appear calm and in control. Do not show anger. If physical restraints are used, move without hesitation in an organized manner restraining all limbs. Explain to the patient that control was being maintained for them until self-control can be restored. Document clearly the mental status of the patient and threat of danger posed for themselves or others. Document interventions attempted to decelerate the patient, but were unsuccessful. If there were injuries to the patient, staff, or visitors, fill out an incident report.

Review of the facility's Code Man Policy, revised March 2011, revealed the purpose of the policy was to recruit assistance in preventing a non-armed, agitated, confused, and/or combative person from causing injury to self or others. Crisis Situation Management (CSM) training was provided for responders from the Security Department, Emergency Department, Plant Engineering Department, and designated staff from Environmental Services. Staff responding from other departments (Nursing and Transport) respond for manpower purposes (i.e. assist with physical control of combative person) under direct supervision of CSM trained personnel. Available Security personnel and trained CSM personnel respond to the announced location as quickly and safely as possible. If the situation is determined to be a medical crisis, nursing staff direct the actions of the responders, if the situation becomes threatening to staff, Security directs the action of the responders. In the event injury occurred to the patient, staff, or visitor, a reportable event form would be completed. Employees are sent to the ED or Employee Health.

Review of the facility's Patient Rights and Responsibly Policy, revision date of March 2012 and reviewed date of 04/23/14, revealed the purpose of the policy is to inform, promote, and protect the basic rights of the patients to treatment, care, and services within the facility's capability and mission in compliance with applicable laws and regulations. The policy stated the patient had the right to receive fair compassionate care at all times and under all circumstances. The patient had the right to receive care in a safe setting, to be free from abuse and harassment, and have access to protective services as needed.

Review of Patient #1's clinical record revealed the patient was brought to the Emergency Department (ED) on 02/06/16 at 4:41 PM via the police. According to the ED physician's clinical report, the police had found the patient wandering in the street barefoot and acting incoherent. The patient was making statements about being Jesus and exhibited unusual behavior. The chief complaint listed was withdrawal with delusions and hallucinations. This had started the night before. The physician documented the patient's symptoms were described as severe. A drug screen was performed and the patient tested positive for amphetamines and marijuana (THC).

Review of the History and Physical, dated 02/07/16, revealed the patient was admitted to the Psych Unit on a seventy-two (72) hour hold, after in the ED the patient was noted to be psychotic, very paranoid and attempted to leave the ED. Upon admission to the Psych Unit, the patient appeared to be very apprehensive. The physician ordered medication that included Haldol, Benadryl and Ativan. The patient accepted the medications. Suddenly, the patient became agitated and aggressive and began kicking, punching, and fighting the security officers. During this encounter, the patient was injured, that included forehead laceration and nose bleed. A Computerized Tomography (CT) scan revealed the patient sustained a nose fracture of the right nasal bone and required sutures for the laceration to the forehead. The attending physician interviewed the patient the next day (02/07/16) and the patient said he/she remembered bits and pieces of what happened to him/her. The patient told the physician he/she experienced visual and auditory hallucinations and felt very scared and apprehensive. The physician documented the patient's insight, judgment, and impulse control as significantly impaired. Diagnostic impression severe drug use of amphetamine and marijuana and substance-induced psychosis.

Review of the Hospitalist's consult documentation (on 02/07/16) to evaluate Patient #1's injuries after the altercation with the security officers, revealed jagged laceration to the forehead with edema and tenderness. In addition, the nasal bones were assessed to be swollen into the bilateral super maxillary soft tissue. Contusions were noted on the left mid-calf and right posterior elbow. The Hospitalist documented the patient had multiple abrasions and contusions. He requested the patient's laceration to the forehead be treated in the ED.
Review of the ED records revealed physical restraints were applied, on 02/06/16 at 6:10 PM, due to the patient bolting out of the ED room. The local police were in the ED (for another reason) and assisted the patient back in the ED bed. The reason for the physical restraints was the patient exhibited violent behavior including imminent risk of harm to self or others. Four-point restraints were applied. The one hour face to face restraint assessment was performed at 7:55 PM and documented the patient was agitated and confused.

Review of the nursing admission note, dated 02/06/16, revealed Patient #1 was admitted to the Psychiatric Unit at 8:45 PM under an involuntary seventy-two (72) hour hold with a diagnosis of Drug Induced Psychosis. Report from the ED nurse stated the patient had history of Psychosis and Substance Abuse. The nurse reported the patient's eyes were dilated and the drug screen test was positive for amphetamine and marijuana. The nurse documented the patient had bolted out of the exam room, but was returned and placed in physical restraints. The patient arrived on the Psychiatric Unit in a wheelchair accompanied by two Security Officers. The patient was taken to the Seclusion Room for assessment. The patient initially resisted moving from the wheelchair to the bed, but did with several directions and reassurance from staff. The patient was religiously preoccupied stating the nurse was the devil and asked that staff kill him/her because he/she needed to die for them. Due to the patient's psychotic agitated state, medication was ordered and admistered. The patient was given Haldol 5 mg (1), Benadryl 50mg (1), and Ativan 2 mg (1) via mouth. The patient took the medication with some hesitation at 9:50 PM. The patient was placed in seclusion due to the agitation and psychosis. The nurse left the seclusion room then returned to perform vital signs and a physical assessment. The door to the Seclusion Room had been locked with both Security Officers present in the Transition (Ante) Room. The patient was cooperative at that time. RN #1 returned to the nurses' station leaving RN #2 and the two Security Officers in the seclusion room with the patient. While at the nurses' station, RN #1 saw the patient stand up on the bed from the monitors at the Nurses' Station. The nurse documented she went to the Seclusion Room to assess the situation. She found one Security Officer struggling with the patient on the floor. A Code Man was called due to out of control and aggressive behaviors. The patient was placed back into seclusion with one to one staff monitoring.

On 02/17/16 at 12:36 PM, a meeting was held with the following facility Administrative staff: Chief Executive Officer; Director of Compliance; Vice President; Chief Nursing Officer; Director of Risk Management; Director of Quality Management; and Chief Medical Officer. The Director of Risk Management conducted the facility's internal investigation of the alleged physical abuse. He stated he learned of the alleged abuse on 02/08/16 after reading written statements from facility staff working the night of the alleged abuse. He stated he immediately set up interviews with all staff involved. He stated after those interviews, it was the first time there was an indication of abuse. He stated the interviews with RN #1 and Security Officer #2, on 02/09/16, revealed they had witnessed the alleged abuse and he learned Patient #1 had sustained injury. On 02/10/16, the Administrative staff determined the need to report the alleged abuse to the State Agency-DCBS.

The Director of Risk Management stated a report given to him revealed the patient had become extremely violent and had injured two Security Officers and RN #2. The report revealed the patient had sustained injury, but indicated the injuries were sustained during the struggle with staff. The report stated the patient had been struck in the act of trying to restrain the patient. The report stated it took three (3) big men to contain the patient. The House Manager voiced concern about the patient getting out of hand again. The patient was seen by a Hospitalist to assess the patient's injuries. The Hospitalist ordered a CT scan that revealed a nasal fracture and ordered for the patient to be seen in the ED for the laceration to the forehead that required sutures. A psychiatric consult was ordered for a possible transfer to another psychiatric hospital. The Risk Manager stated RN #1 reported what she witnessed to the House Manager and he informed the Administrator On-Call (Chief Medical Officer). The alleged abuse occurred, on 02/06/16 at 9:00 PM, in the Psych Unit. The patient had been discharged from the facility on 02/10/16.

Interview with the Chief Medical Officer during the above meeting revealed he was informed of the violent incident between Patient #1 and the staff; however, what was reported to him was the patient had struck and injured the staff and had sustained injury during that altercation. He stated he was notified for medical advice and he instructed the House Manager to obtained medical treatment for the staff and the patient. He stated abuse was not reported to him and it was not reported Security Officer #1 or RN #2 had hit the patient. He was unaware of the allegation until the Director of Risk Management informed him on Monday, 02/08/16.

Interview with the Director of the Psychiatric Unit, on 2/17/16 at 1:21 PM, revealed she was not working the night of the incident. She stated she received a text from the Unit Manager stating there was an incident of assault on the unit. She stated two nurses were working the night of the incident, but RN #1 was the patient's primary nurse. She stated the doors to the seclusion room were locked. It was reported to her RN #1 had observed the patient standing up on the bed on the monitors at the Nurses' Station. The nurse then went to assess the situation. Review of the Director's phone text revealed she received the text from the Unit Manager at 10:27 PM on 02/06/16. Review of the text revealed a report of an assault on the unit and that she would discuss the matter on Monday, 02/08/16. The Director stated she met with the Unit Manager on 02/08/16 to discuss the incident. The Unit Manager told the Director she had written statements from the staff. She spoke with the Chief Nursing Officer (CNO) on Monday (02/08/16) and filled her in on the details. She met with the Director of Risk Management on Tuesday regarding the concerns about this case.

Interview with Security Officer #2, on 02/17/16 at 3:01 PM, revealed he had been rehired to work at the facility a little over a year ago. He stated the night of the incident he escorted the patient from the ED to the Psych Unit. He stated it was the facility's policy to have two security officers to escort a patient to the Psych Unit. He stated the patient was put into the seclusion room. The patient cooperated with the nurse when she assessed the patient and gave him/her medication. He stated the nurses left and went to the Nurses' Station and the seclusion room door was locked. Security Officer #1 had walked to the Nurses' station to get the wand to detect metal. The Security Officers used the device to search for knives and other sharp devices. The officer found none. The patient was dressed in paper scrubs with the patient's street clothing removed in the ED per protocol. Once the patient had been searched, the nurses left and he went into the Ante room (small entrance room outside the seclusion room). Security Officer #1 was the last one to leave the seclusion room. When this officer left the room, the patient was laying on the bed not speaking. Very quickly the patient jump up on top of the bed and said, "You come here." He was pointing to Security Officer #1. The patient started ripping of the paper top and Security Officer #1 told the patient he/she didn't have to take off the top. The patient then said, "You are not going anywhere". Security Officer #1 pushed the patient off the bed to the wall. The patient began swinging and trying to hit the officer. He went back into the seclusion room and observed Security Officer #1 fall onto the floor with the patient on top of him. The patient was hitting the Officer #1 on the head. He pulled the patient off the other officer and the patient started hitting him in the face. The patient hit Security Officer #2 in the lip and jaw twice. He pushed the patient off him and at the same time RN #2 came back into the room and the patient went after him. The patient ran from the Seclusion Room into the Ante room. By that time, Security Officer #1 was back on his feet and went after the patient. He pushed the patient into a corner of the Ante room and placed his body over the patient's to hold him/her down. He called a Code Man, but before the team could arrive to help, he observed Security Officer #1 place the patient into a head lock and punch the patient in the face with his fist. He heard Security Officer #1 tell RN #2 to hit the patient in the face and he did. The patient began bleeding from the face. He stated he didn't say anything about what he saw at that time. Then RN #1 came to the door and brought restraints. However, there were only three (3) restraints and they needed four (4). He left the room to search for another limb restraint. The Code Man team had responded by that time. When he returned with the fourth restraint, the patient was on the bed in the seclusion room, cooperative, bleeding from the face. The patient refused treatment for the injuries at that time so the staff locked the door and left the patient. He did not know if what he saw was abuse or not. He had not reported it as abuse. He could not recall if he had training on abuse. He should have reported the abuse to the Security Manager. He recalled Security Officer #1 worked the next day. He stated he had no training in CSM techniques.

Review of Security Officer #2's written statement revealed the same details the officer stated in his interview. He wrote he had witnessed Security Officer #1 place Patient #1 in a head hold and punched the patient in the face with his fist several times. He also wrote he witnessed RN #2 hit the patient in the face with his fist.

Interview with RN #1, on 02/17/16 at 3:35 PM, revealed she was Patient #1's nurse the night of the alleged abuse. She stated she received report from the ED nurse that the patient was quiet in the ED, but attempted to leave. Once on the unit, she assessed the patient in the Seclusion Room and the patient appeared to be anxious. She stated the patient was delusional calling her the devil and the patient could not follow directions. She obtained an order and administered medications to calm the patient. The patient refused the medication at first but then agreed to take the medications. She took the patient's vital signs and performed a physical assessment. The patient was sitting up on the bed, looking around like he was paranoid. She then left the Seclusion Room and went back to the Nurses' Station. The Security Officers were left with the patient. She stated she heard a commotion and looked at the monitors and saw Patient #1 standing up on the bed. She then saw a struggle between Security Officer #1 and the patient, and then they went out of the camera's frame. She immediately went to the Seclusion Room. When she pushed the Ante Room door opened she saw the patient on the floor with Security Officer #1's body on top of him holding the patient down. The two Security Officers and RN #2 were in the small room with the patient. She witnessed Security Officer #1 hit the patient in the face with a closed fist several times. She told him to stop because they could not do that. The other officer (#2) touched Security Officer #1's hand and said, "Stop Man" and the officer finally stopped. She did not see RN #2 hit the patient, but she was not present the whole time. She told the House Manager what she had witnessed. He told Security Officer #1 to get treatment and then go home. The patient had a laceration to the forehead. A medical consult was obtained with order for a Computerized Tomography (CT) scan. The CT scan revealed the patient had a fracture nose. The patient went to the ED for sutures of the laceration on the forehead. She stated the patient was placed back into the Seclusion Room without any other outburst.

Review of RN #1's written statement revealed the patient was received from the ED, on 02/06/16 at 8:45 PM. The patient was taken to the Seclusion Room. The patient was found to be religiously preoccupied and made statements that the nurse was the devil. The nurse documented she was working on paperwork when she heard a disturbance from the Seclusion Room. She looked at the camera monitor and saw the patient standing on top of the bed and there was a physical struggle between Security Officer #1 and the patient. She went to assess the situation and when she tried to open the door, she could not because Security Officer #2 had his arm against the door. When he moved his arm and she looked inside the door, she saw the patient lying on his back, on the floor, with Security Officer #1's body on top of the patient. She saw Security Officer #1 draw back his closed fist and strike the patient three (3) times in the face. She told him to stop because they could not hit patients. The officer drew back his fist again and then Security Officer #2 asked him to stop and he did. A Code Man was called and the patient was assisted back to the bed in the seclusion room. She noticed a significant amount of blood on the floor. The patient had an area to the forehead and blood on the right shoulder. The House Manager was called to the unit and informed of the incident. The patient was placed in four-point restraints for exam. The patient had a CT completed that was positive for nasal bone fracture. The patient required sutures in the ED for the laceration to the forehead.

Interview with Security Officer #1, on 02/18/16 at 10:00 AM, revealed he had been employed by the facility for over three (3) years. He stated he first saw the patient in the ED wandering around. He assisted the ED staff to apply physical restraints. He stated the patient was not aggressive in the ED. He transported the patient to the Psych Unit with Security Officer #2. The patient had not spoken during the transport. The patient was placed in the seclusion room and requested to sit on the bed. It took several requests, but the resident finally sat on the bed. The patient's eyes were dilated and the patient had a blank angry look on his/her face. Security Officer #2 observed RN #2 give the patient some medications. He said the patient just laid on the bed while he ran the wand over the patient's body to search for metal objects. The officer stated they were leaving the seclusion room when the patient asked him if he would forgive him/her. The patient asked if God would forgive him/her and then said "I don't think he will this time". The patient was still lying on the bed flat. The officer stated there was something in the patient's tone of voice and then his/her face changed to a blank stare. The patient jumped from the bed, and tore off the paper shirt. The officer stated, "What are doing?" He told the patient the search was over. The patient then told the officer, "You are not going anywhere" while he/she was pointing their finger at him. The officer stated he tried to leave the room, but the patient jumped on top of the bed and was coming toward him. He took his left hand and pushed the patient off the bed and he landed on his/her feet. The officer stated he could not recall all the details, but he tried to grab the patient, fell to the floor and the patient was hitting him in the head several times. Security Officer #2 got the patient off the officer and then the patient started hitting him. The patient ran around the bed to get out the door and RN #2 was standing there. The patient hit RN #2. The patient made it into the Ante room. He was on his feet then and tried to grab the patient around the arms. He stated "he didn't have a choice". He put the patient in the floor, corner of the Ante room. He had his right arm around the patient and hit him with his left hand several times. They both went onto the floor. His body covered his/her. He recalled putting the patient in a head lock. He stated his left arm had blood on it, but it was not his, it was the patient's.

Continued interview with Security Officer #1 revealed he had "Zero" training on how to deal with combative or aggressive patients. He stated that was the first time he had encountered an incident like that. He had CSM class when he first started working at the facility three (3) years ago. He did not recall any training on abuse. The officer didn't know how many times he hit the patient. He stated he had no training on CSM holds. He said he feared for his life, he was attached and fought back. The officer stated after the Code Man was called and the team came to assist, he went to the ED for treatment. He stated his manager came in for coverage and requested him to provide a written statement. Security Officer #1 revealed he worked the next day and was on the Psychiatric Unit two times making rounds. He saw the patient in the dayroom, and had no communication with the patient. He stated he was called in to speak with the Risk Management Director on Monday, 02/09/16. He was suspended on 02/10/16. He stated he was only doing his job. He felt like he was not trained and was afraid.

Review of the written statement by Security Officer #1 revealed the officer admitted to pushing the patient off the bed. He documented he struck the patient in the forehead. The officer documented the patient fell down and he laid on top of him with the patient' arms restrained while he waited for the Code Man team. The officer wrote he acted justly and appropriately under the facility's force policy and felt he had handled the difficult situation the best he could. However, interviews with the Administrative staff and review of facility policies revealed there was no force policy the officer referred to.

Interview with RN #2, on 02/18/16 at 11:05 AM, revealed he had only worked in the Psych Unit since August 2015. He revealed he was only helping RN #1 that night because Patient #1 was not assigned to him. When the patient was admitted to the unit he/she was placed in the seclusion room. The patient was delusional calling RN #1 the devil and the patient was Jesus Christ and he/she needed to sacrifice his/her life for their sins and save man-kind. The patient was given medications to calm down. He stated the patient was left alone in the locked seclusion room for a short while. The patient was lying on the bed quietly. The two Security Officers were in the Ante Room just outside the seclusion room.
Security Officer #1 went to the Nurses' Station to get the wand. The nurses and Security Officer #1 walked back to the seclusion room opened the door and everyone went in. The patient was resistive of taking the medication at first, but then took the medication. The patient was calm. RN #1 left the seclusion room first followed by RN #2 and Security Officer #2. Security Officer #1 was in the doorway attempting to leave. The patient yelled at Security Officer #1, "Hey, tall guy, I need to talk to you." RN #2 turned and heard the patient say he/she was sorry for his/her behavior in the ED. Security Officer #1 told the patient he/she didn't do anything wrong by him. All of a sudden, the patient stood up on the bed and took off his/her scrub top. Security Officer #1 told the patient they didn't do those types of searches. The patient then lunged at the officer and the officer pushed back. Security Officer #1 lost his balance and fell to the floor. The patient jumped on top of him and started hitting the officer in the head. The nurse stated everything happened so fast and then Security Officer #2 came into the seclusion room and got the patient off Security Officer #1. The patient started hitting Security Officer #2. Then the patient charged at RN #2 and hit him in the face. The officers had time to recover and pushed the patient into the Ante room. Patient #1 was still on his/her feet at that time. Officer #1 was trying to hold the patient, but the patient was swinging his/her arms uncontrollably. Officer #1 got behind the patient and told the nurse to hit the patient. RN #2 stated he put his arm out and made contact with the patient's face. The patient and Officer #1 fell onto the floor of the Ante Room. The officer took the patient down. The officer had his body over the patient's and yelled to call a Code Man and Police. That is when the patient said, "I'm done", "I'm done." The nurse stated he looked at the patient and Officer #1 and the patient was not fighting and was not bleeding. He stated he was rubbing his jaw where he had been hit when RN #1 opened the door to the Ante Room and yelled. "You all can't do that." He looked up and saw Security Officer #1 hitting the patient in the face with his closed fist. Officer #2 yelled at that officer, "Man stop", "Man stop." That is when RN #2 saw blood coming from the patient's face. This nurse denied he hit the patient with his fist or opened hand when the patient stated he/she was done.

Continued interview with RN #2 revealed he had never encountered a situation like that before and he was afraid. He stated there was no time to de-escalate the situation. He stated he had CSM training and he thought they went over a few specific holds, but he froze when the patient hit him and he was afraid. He admitted he had struck the patient two (2) times, but it was when the patient was still standing and he was trying to stop the patient and help Officer #1 bring the patient down. He stated the patient was quiet after

Based on interviews, record review, and review of the facility's policies and documents, it was determined the facility failed to protect and promote patient rights, prevent physical abuse, and provide care in a safe setting for one (1) of twelve (12) sampled patients. Patient #1 was admitted to the Psychiatric Unit and placed in a closed seclusion room on 02/06/16 after evaluation in the Emergency Department (ED). The patient was brought to the ED by the police due to the patient having been found wandering in the street, barefoot, and acting incoherent. The ED listed the chief complaint to be the patient was delusional with hallucinations. A drug screen was performed and the patient tested positive for amphetamine and marijuana (THC). A seventy-two (72) hour hold was obtained for treatment. Once the patient was admitted to the Psychiatric Unit, the patient became aggressive and violent with the staff. The patient attacked two Security Officers and a nurse. During the altercation, Security Officer #1 and Registered Nurse (RN) #2 was witnessed to strike the patient in the face several times with a closed fist. The patient sustained a fractured nose and laceration to the forehead that required sutures.

In addition, the facility failed to ensure the nursing staff were properly trained to control a crisis situation and the facility failed to implement appropriate Crisis Situation Management (CSM) techniques and found the staff involved in the altercation with Patient #1 had not been properly trained. The Security Officers had not received abuse training and review of the abuse training provided to the nurses revealed employee to patient abuse was not discussed. Interviews with staff revealed the alleged physical abuse was reported to the House Manager and written statements were obtained. However, the manager failed to report the alleged abuse to the Administrative On-Call person and the facility did not report the alleged abuse to the Department of Community Based Services (DCBS) until 02/10/16, four (4) days after the alleged abuse occurred. Security Officer #1 and RN #2 were allowed to work after the alleged abuse and were in contact with the patient.

The facility identified the event to be a serious safety event and the investigation was still ongoing during the survey. The facility identified a root cause analysis that staff were not properly trained, the abuse policy was not clear regarding reporting, and corrective actions had not been implemented.

The facility's failure to ensure Patient #1 received care in a safe setting, ensure patients were not abused, to train staff on CSM and abuse reporting, and failure to report the alleged abuse and implement corrective actions placed Patient #1 and all patients in the facility at risk for serious injury, harm, impairment or death.


Refer to A144, A145 and A397.

Based on observation, interviews, record review, and review of the facility's policies and documents, it was determined the facility failed to ensure patients were free from abuse for one (1) of twelve (12) sampled patients. Patient #1 was admitted to the Psychiatric Unit for an involuntary seventy-two (72) hour hold for close monitoring of drug induced Psychosis on 02/06/16. Staff interviews and nursing assessments revealed the patient was religiously preoccupied and in an agitated state. The patient was placed in a locked seclusion room and given medication to help calm the patient. The patient became aggressive toward Security Officer #1 and then attacked the officer. There was a struggle with the patient. During the struggle two Security Officers and the patient was brought down to the floor. It was witnessed that Security Officer #1 placed the patient in a head lock and hit the patient in the face several times with his closed fist. The patient sustained a fracture nose and laceration to the forehead that required sutures in the Emergency Department (ED). In addition, Registered Nurse (RN) #2 was witnessed to hit the patient in the face during the altercation with the patient. RN #1 reported the alleged physical abuse to the House Manager on 02/06/16; however, he failed to investigate the allegation or report the allegation to Administrative staff according to the facility's Abuse Policy until 02/08/16. The facility failed to report the alleged abuse to the State Agency until 02/10/16, four days after the alleged abuse occurred. Security Officer #1 and Registered Nurse (RN) #2 were allowed to work with the patient after the alleged abuse had occurred.


In addition, the facility failed to implement appropriate Crisis Situation Management (CSM) techniques and failed to report the alleged abuse to the appropriate State Agency and protect the patient from further abuse.

Refer to A144, A145, and A397.


The findings include:

1. Review of the facility's Abuse Policy, revised date of 08/20/14 and 11/18/14, revealed the purpose of the Abuse Policy was to protect patient's rights to be free from abuse and to establish appropriate procedures for responding to reports of abuse, neglect, or exploitation. The policy stated the patient had a right to be free from verbal, physical, mental, or other abuse, including neglect and exploitation. Such abuse would not be tolerated from any employee, volunteer, student, physician, patient, visitor, or other individual. Under the definition of physical abuse included but not limited to, hitting, slapping, punching and kicking. Physical abuse also included controlling a patient's behavior through corporal punishment. Allegations made against a facility employee must be reported by the first person becoming aware of the allegation. That person would notify the Department/Unit Manager or House Manager who would ensure that immediate measures necessary are taken for patient safety, and then notify the following persons: Department Director; Vice President; Administrator On-Call; Attending Physician; Director of Risk Management; and Social Services (who report the allegation to the Department of Protection and Permanency as appropriate). The Department/Unit Manager or House Manager would obtain a detailed statement from the patient/family member making the allegation. There was nothing in the policy to direct staff on what to do if they observed an employee abuse a patient. The policy stated generally, an employee was suspended pending further investigation of allegations of patient abuse.

Review of the Abuse Policy specific to the Psychiatric Unit, revised date 10/26/15, revealed this policy applied to all trained care providers and Psychiatric Unit staff. The procedure stated nursing would complete assessment of patient's report of abuse. Nursing would document all available information in the medical record including nature of the reported abuse, time it occurred, and injuries received. Nursing would inform the Social Worker and if unable to reach, leave a message. The Social Worker evaluates the patient's report, makes referrals, and documents the referral. A reporting form was attached to this policy that was designed for abuse allegations which occurred outside the facility such as domestic violence and not for employee to patient abuse.

Review of the Department for Community Based Services (DCBS) tracking ID intake form revealed the facility notified the state agency of the allegation of physical abuse, on 02/10/16 at 3:35 PM, four days after the alleged abuse had occurred.

Review of the Patient's Rights for Protective Service Policy, reviewed 06/30/14 and revised May 2012, revealed the purpose of the policy was to provide patients information/services necessary to ensure their protection related to Abuse/Neglect and Exploitation. The policy referenced KRS 209.30.

Review of the Assault or Violent Behavior Policy, revised 10/26/15, revealed the policy was created specific for the Psychiatric Unit. The purpose was to ensure nursing was knowledgeable of behavior indicating potentially dangerous situations. The policy applied to all trained care providers, Psychiatric Unit staff, and Security Department staff. Stage I of the policy instructed staff to be alert to patients posing a higher risk of violent behaviors that included paranoia, inability to concentrate, increased voice volume, substance withdrawal, and psychosis-auditory or visual hallucinations. The key point was to notify the physician of escalating behaviors. Stage II was to call a "Code Man". Staff members participating in a "Code Man" are well trained in body mechanics and methods of holding a struggling patient without causing injury; maintaining a comfortable distance (beyond the reach of hands/feet) from the patient; face the patient and maintain an exit at your back; only one person should talk with the patient; a staff member would be assigned to restrain each limb. When a patient's out of control state is acknowledged, tell the patient the staff are prepared to maintain control of him/her until they regain self-control. Tell the patient what you want them to do. Use the least amount of force necessary. Try to appear calm and in control. Do not show anger. If physical restraints are used, move without hesitation in an organized manner restraining all limbs. Explain to the patient that control was being maintained for them until self-control can be restored. Document clearly the mental status of the patient and threat of danger posed for themselves or others. Document interventions attempted to decelerate the patient, but were unsuccessful. If there were injuries to the patient, staff, or visitors, fill out an incident report.

Review of the facility's Code Man Policy, revised March 2011, revealed the purpose of the policy was to recruit assistance in preventing a non-armed, agitated, confused, and/or combative person from causing injury to self or others. Crisis Situation Management (CSM) training was provided for responders from the Security Department, Emergency Department, Plant Engineering Department, and designated staff from Environmental Services. Staff responding from other departments (Nursing and Transport) respond for manpower purposes (i.e. assist with physical control of combative person) under direct supervision of CSM trained personnel. Available Security personnel and trained CSM personnel respond to the announced location as quickly and safely as possible. If the situation is determined to be a medical crisis, nursing staff direct the actions of the responders, if the situation becomes threatening to staff, Security directs the action of the responders. In the event injury occurred to the patient, staff, or visitor, a reportable event form would be completed. Employees are sent to the ED or Employee Health.

Review of the facility's Patient Rights and Responsibly Policy, revision date of March 2012 and reviewed date of 04/23/14, revealed the purpose of the policy is to inform, promote, and protect the basic rights of the patients to treatment, care, and services within the facility's capability and mission in compliance with applicable laws and regulations. The policy stated the patient had the right to receive fair compassionate care at all times and under all circumstances. The patient had the right to receive care in a safe setting, to be free from abuse and harassment, and have access to protective services as needed.

Review of Patient #1's clinical record revealed the patient was brought to the Emergency Department (ED) on 02/06/16 at 4:41 PM via the police. According to the ED physician's clinical report, the police had found the patient wandering in the street barefoot and acting incoherent. The patient was making statements about being Jesus and exhibited unusual behavior. The chief complaint listed was withdrawal with delusions and hallucinations. This had started the night before. The physician documented the patient's symptoms were described as severe. A drug screen was performed and the patient tested positive for amphetamines and marijuana (THC).

Review of the History and Physical, dated 02/07/16, revealed the patient was admitted to the Psych Unit on a seventy-two (72) hour hold, after in the ED the patient was noted to be psychotic, very paranoid and attempted to leave the ED. Upon admission to the Psych Unit, the patient appeared to be very apprehensive. The physician ordered medication that included Haldol, Benadryl and Ativan. The patient accepted the medications. Suddenly, the patient became agitated and aggressive and began kicking, punching, and fighting the security officers. During this encounter, the patient was injured, that included forehead laceration and nose bleed. A Computerized Tomography (CT) scan revealed the patient sustained a nose fracture of the right nasal bone and required sutures for the laceration to the forehead. The attending physician interviewed the patient the next day (02/07/16) and the patient said he/she remembered bits and pieces of what happened to him/her. The patient told the physician he/she experienced visual and auditory hallucinations and felt very scared and apprehensive. The physician documented the patient's insight, judgment, and impulse control as significantly impaired. Diagnostic impression severe drug use of amphetamine and marijuana and substance-induced psychosis.

Review of the Hospitalist's consult documentation (on 02/07/16) to evaluate Patient #1's injuries after the altercation with the security officers, revealed jagged laceration to the forehead with edema and tenderness. In addition, the nasal bones were assessed to be swollen into the bilateral super maxillary soft tissue. Contusions were noted on the left mid-calf and right posterior elbow. The Hospitalist documented the patient had multiple abrasions and contusions. He requested the patient's laceration to the forehead be treated in the ED.
Review of the ED records revealed physical restraints were applied, on 02/06/16 at 6:10 PM, due to the patient bolting out of the ED room. The local police were in the ED (for another reason) and assisted the patient back in the ED bed. The reason for the physical restraints was the patient exhibited violent behavior including imminent risk of harm to self or others. Four-point restraints were applied. The one hour face to face restraint assessment was performed at 7:55 PM and documented the patient was agitated and confused.

Review of the nursing admission note, dated 02/06/16, revealed Patient #1 was admitted to the Psychiatric Unit at 8:45 PM under an involuntary seventy-two (72) hour hold with a diagnosis of Drug Induced Psychosis. Report from the ED nurse stated the patient had history of Psychosis and Substance Abuse. The nurse reported the patient's eyes were dilated and the drug screen test was positive for amphetamine and marijuana. The nurse documented the patient had bolted out of the exam room, but was returned and placed in physical restraints. The patient arrived on the Psychiatric Unit in a wheelchair accompanied by two Security Officers. The patient was taken to the Seclusion Room for assessment. The patient initially resisted moving from the wheelchair to the bed, but did with several directions and reassurance from staff. The patient was religiously preoccupied stating the nurse was the devil and asked that staff kill him/her because he/she needed to die for them. Due to the patient's psychotic agitated state, medication was ordered and admistered. The patient was given Haldol 5 mg (1), Benadryl 50mg (1), and Ativan 2 mg (1) via mouth. The patient took the medication with some hesitation at 9:50 PM. The patient was placed in seclusion due to the agitation and psychosis. The nurse left the seclusion room then returned to perform vital signs and a physical assessment. The door to the Seclusion Room had been locked with both Security Officers present in the Transition (Ante) Room. The patient was cooperative at that time. RN #1 returned to the nurses' station leaving RN #2 and the two Security Officers in the seclusion room with the patient. While at the nurses' station, RN #1 saw the patient stand up on the bed from the monitors at the Nurses' Station. The nurse documented she went to the Seclusion Room to assess the situation. She found one Security Officer struggling with the patient on the floor. A Code Man was called due to out of control and aggressive behaviors. The patient was placed back into seclusion with one to one staff monitoring.

On 02/17/16 at 12:36 PM, a meeting was held with the following facility Administrative staff: Chief Executive Officer; Director of Compliance; Vice President; Chief Nursing Officer; Director of Risk Management; Director of Quality Management; and Chief Medical Officer. The Director of Risk Management conducted the facility's internal investigation of the alleged physical abuse. He stated he learned of the alleged abuse on 02/08/16 after reading written statements from facility staff working the night of the alleged abuse. He stated he immediately set up interviews with all staff involved. He stated after those interviews, it was the first time there was an indication of abuse. He stated the interviews with RN #1 and Security Officer #2, on 02/09/16, revealed they had witnessed the alleged abuse and he learned Patient #1 had sustained injury. On 02/10/16, the Administrative staff determined the need to report the alleged abuse to the State Agency-DCBS.

The Director of Risk Management stated a report given to him revealed the patient had become extremely violent and had injured two Security Officers and RN #2. The report revealed the patient had sustained injury, but indicated the injuries were sustained during the struggle with staff. The report stated the patient had been struck in the act of trying to restrain the patient. The report stated it took three (3) big men to contain the patient. The House Manager voiced concern about the patient getting out of hand again. The patient was seen by a Hospitalist to assess the patient's injuries. The Hospitalist ordered a CT scan that revealed a nasal fracture and ordered for the patient to be seen in the ED for the laceration to the forehead that required sutures. A psychiatric consult was ordered for a possible transfer to another psychiatric hospital. The Risk Manager stated RN #1 reported what she witnessed to the House Manager and he informed the Administrator On-Call (Chief Medical Officer). The alleged abuse occurred, on 02/06/16 at 9:00 PM, in the Psych Unit. The patient had been discharged from the facility on 02/10/16.

Interview with the Chief Medical Officer during the above meeting revealed he was informed of the violent incident between Patient #1 and the staff; however, what was reported to him was the patient had struck and injured the staff and had sustained injury during that altercation. He stated he was notified for medical advice and he instructed the House Manager to obtained medical treatment for the staff and the patient. He stated abuse was not reported to him and it was not reported Security Officer #1 or RN #2 had hit the patient. He was unaware of the allegation until the Director of Risk Management informed him on Monday, 02/08/16.

Interview with the Director of the Psychiatric Unit, on 2/17/16 at 1:21 PM, revealed she was not working the night of the incident. She stated she received a text from the Unit Manager stating there was an incident of assault on the unit. She stated two nurses were working the night of the incident, but RN #1 was the patient's primary nurse. She stated the doors to the seclusion room were locked. It was reported to her RN #1 had observed the patient standing up on the bed on the monitors at the Nurses' Station. The nurse then went to assess the situation. Review of the Director's phone text revealed she received the text from the Unit Manager at 10:27 PM on 02/06/16. Review of the text revealed a report of an assault on the unit and that she would discuss the matter on Monday, 02/08/16. The Director stated she met with the Unit Manager on 02/08/16 to discuss the incident. The Unit Manager told the Director she had written statements from the staff. She spoke with the Chief Nursing Officer (CNO) on Monday (02/08/16) and filled her in on the details. She met with the Director of Risk Management on Tuesday regarding the concerns about this case.

Interview with Security Officer #2, on 02/17/16 at 3:01 PM, revealed he had been rehired to work at the facility a little over a year ago. He stated the night of the incident he escorted the patient from the ED to the Psych Unit. He stated it was the facility's policy to have two security officers to escort a patient to the Psych Unit. He stated the patient was put into the seclusion room. The patient cooperated with the nurse when she assessed the patient and gave him/her medication. He stated the nurses left and went to the Nurses' Station and the seclusion room door was locked. Security Officer #1 had walked to the Nurses' station to get the wand to detect metal. The Security Officers used the device to search for knives and other sharp devices. The officer found none. The patient was dressed in paper scrubs with the patient's street clothing removed in the ED per protocol. Once the patient had been searched, the nurses left and he went into the Ante room (small entrance room outside the seclusion room). Security Officer #1 was the last one to leave the seclusion room. When this officer left the room, the patient was laying on the bed not speaking. Very quickly the patient jump up on top of the bed and said, "You come here." He was pointing to Security Officer #1. The patient started ripping of the paper top and Security Officer #1 told the patient he/she didn't have to take off the top. The patient then said, "You are not going anywhere". Security Officer #1 pushed the patient off the bed to the wall. The patient began swinging and trying to hit the officer. He went back into the seclusion room and observed Security Officer #1 fall onto the floor with the patient on top of him. The patient was hitting the Officer #1 on the head. He pulled the patient off the other officer and the patient started hitting him in the face. The patient hit Security Officer #2 in the lip and jaw twice. He pushed the patient off him and at the same time RN #2 came back into the room and the patient went after him. The patient ran from the Seclusion Room into the Ante room. By that time, Security Officer #1 was back on his feet and went after the patient. He pushed the patient into a corner of the Ante room and placed his body over the patient's to hold him/her down. He called a Code Man, but before the team could arrive to help, he observed Security Officer #1 place the patient into a head lock and punch the patient in the face with his fist. He heard Security Officer #1 tell RN #2 to hit the patient in the face and he did. The patient began bleeding from the face. He stated he didn't say anything about what he saw at that time. Then RN #1 came to the door and brought restraints. However, there were only three (3) restraints and they needed four (4). He left the room to search for another limb restraint. The Code Man team had responded by that time. When he returned with the fourth restraint, the patient was on the bed in the seclusion room, cooperative, bleeding from the face. The patient refused treatment for the injuries at that time so the staff locked the door and left the patient. He did not know if what he saw was abuse or not. He had not reported it as abuse. He could not recall if he had training on abuse. He should have reported the abuse to the Security Manager. He recalled Security Officer #1 worked the next day. He stated he had no training in CSM techniques.

Review of Security Officer #2's written statement revealed the same details the officer stated in his interview. He wrote he had witnessed Security Officer #1 place Patient #1 in a head hold and punched the patient in the face with his fist several times. He also wrote he witnessed RN #2 hit the patient in the face with his fist.

Interview with RN #1, on 02/17/16 at 3:35 PM, revealed she was Patient #1's nurse the night of the alleged abuse. She stated she received report from the ED nurse that the patient was quiet in the ED, but attempted to leave. Once on the unit, she assessed the patient in the Seclusion Room and the patient appeared to be anxious. She stated the patient was delusional calling her the devil and the patient could not follow directions. She obtained an order and administered medications to calm the patient. The patient refused the medication at first but then agreed to take the medications. She took the patient's vital signs and performed a physical assessment. The patient was sitting up on the bed, looking around like he was paranoid. She then left the Seclusion Room and went back to the Nurses' Station. The Security Officers were left with the patient. She stated she heard a commotion and looked at the monitors and saw Patient #1 standing up on the bed. She then saw a struggle between Security Officer #1 and the patient, and then they went out of the camera's frame. She immediately went to the Seclusion Room. When she pushed the Ante Room door opened she saw the patient on the floor with Security Officer #1's body on top of him holding the patient down. The two Security Officers and RN #2 were in the small room with the patient. She witnessed Security Officer #1 hit the patient in the face with a closed fist several times. She told him to stop because they could not do that. The other officer (#2) touched Security Officer #1's hand and said, "Stop Man" and the officer finally stopped. She did not see RN #2 hit the patient, but she was not present the whole time. She told the House Manager what she had witnessed. He told Security Officer #1 to get treatment and then go home. The patient had a laceration to the forehead. A medical consult was obtained with order for a Computerized Tomography (CT) scan. The CT scan revealed the patient had a fracture nose. The patient went to the ED for sutures of the laceration on the forehead. She stated the patient was placed back into the Seclusion Room without any other outburst.

Review of RN #1's written statement revealed the patient was received from the ED, on 02/06/16 at 8:45 PM. The patient was taken to the Seclusion Room. The patient was found to be religiously preoccupied and made statements that the nurse was the devil. The nurse documented she was working on paperwork when she heard a disturbance from the Seclusion Room. She looked at the camera monitor and saw the patient standing on top of the bed and there was a physical struggle between Security Officer #1 and the patient. She went to assess the situation and when she tried to open the door, she could not because Security Officer #2 had his arm against the door. When he moved his arm and she looked inside the door, she saw the patient lying on his back, on the floor, with Security Officer #1's body on top of the patient. She saw Security Officer #1 draw back his closed fist and strike the patient three (3) times in the face. She told him to stop because they could not hit patients. The officer drew back his fist again and then Security Officer #2 asked him to stop and he did. A Code Man was called and the patient was assisted back to the bed in the seclusion room. She noticed a significant amount of blood on the floor. The patient had an area to the forehead and blood on the right shoulder. The House Manager was called to the unit and informed of the incident. The patient was placed in four-point restraints for exam. The patient had a CT completed that was positive for nasal bone fracture. The patient required sutures in the ED for the laceration to the forehead.

Interview with Security Officer #1, on 02/18/16 at 10:00 AM, revealed he had been employed by the facility for over three (3) years. He stated he first saw the patient in the ED wandering around. He assisted the ED staff to apply physical restraints. He stated the patient was not aggressive in the ED. He transported the patient to the Psych Unit with Security Officer #2. The patient had not spoken during the transport. The patient was placed in the seclusion room and requested to sit on the bed. It took several requests, but the resident finally sat on the bed. The patient's eyes were dilated and the patient had a blank angry look on his/her face. Security Officer #2 observed RN #2 give the patient some medications. He said the patient just laid on the bed while he ran the wand over the patient's body to search for metal objects. The officer stated they were leaving the seclusion room when the patient asked him if he would forgive him/her. The patient asked if God would forgive him/her and then said "I don't think he will this time". The patient was still lying on the bed flat. The officer stated there was something in the patient's tone of voice and then his/her face changed to a blank stare. The patient jumped from the bed, and tore off the paper shirt. The officer stated, "What are doing?" He told the patient the search was over. The patient then told the officer, "You are not going anywhere" while he/she was pointing their finger at him. The officer stated he tried to leave the room, but the patient jumped on top of the bed and was coming toward him. He took his left hand and pushed the patient off the bed and he landed on his/her feet. The officer stated he could not recall all the details, but he tried to grab the patient, fell to the floor and the patient was hitting him in the head several times. Security Officer #2 got the patient off the officer and then the patient started hitting him. The patient ran around the bed to get out the door and RN #2 was standing there. The patient hit RN #2. The patient made it into the Ante room. He was on his feet then and tried to grab the patient around the arms. He stated "he didn't have a choice". He put the patient in the floor, corner of the Ante room. He had his right arm around the patient and hit him with his left hand several times. They both went onto the floor. His body covered his/her. He recalled putting the patient in a head lock. He stated his left arm had blood on it, but it was not his, it was the patient's.

Continued interview with Security Officer #1 revealed he had "Zero" training on how to deal with combative or aggressive patients. He stated that was the first time he had encountered an incident like that. He had CSM class when he first started working at the facility three (3) years ago. He did not recall any training on abuse. The officer didn't know how many times he hit the patient. He stated he had no training on CSM holds. He said he feared for his life, he was attached and fought back. The officer stated after the Code Man was called and the team came to assist, he went to the ED for treatment. He stated his manager came in for coverage and requested him to provide a written statement. Security Officer #1 revealed he worked the next day and was on the Psychiatric Unit two times making rounds. He saw the patient in the dayroom, and had no communication with the patient. He stated he was called in to speak with the Risk Management Director on Monday, 02/09/16. He was suspended on 02/10/16. He stated he was only doing his job. He felt like he was not trained and was afraid.

Review of the written statement by Security Officer #1 revealed the officer admitted to pushing the patient off the bed. He documented he struck the patient in the forehead. The officer documented the patient fell down and he laid on top of him with the patient' arms restrained while he waited for the Code Man team. The officer wrote he acted justly and appropriately under the facility's force policy and felt he had handled the difficult situation the best he could. However, interviews with the Administrative staff and review of facility policies revealed there was no force policy the officer referred to.

Interview with RN #2, on 02/18/16 at 11:05 AM, revealed he had only worked in the Psych Unit since August 2015. He revealed he was only helping RN #1 that night because Patient #1 was not assigned to him. When the patient was admitted to the unit he/she was placed in the seclusion room. The patient was delusional calling RN #1 the devil and the patient was Jesus Christ and he/she needed to sacrifice his/her life for their sins and save man-kind. The patient was given medications to calm down. He stated the patient was left alone in the locked seclusion room for a short while. The patient was lying on the bed quietly. The two Security Officers were in the Ante Room just outside the seclusion room.
Security Officer #1 went to the Nurses' Station to get the wand. The nurses and Security Officer #1 walked back to the seclusion room opened the door and everyone went in. The patient was resistive of taking the medication at first, but then took the medication. The patient was calm. RN #1 left the seclusion room first followed by RN #2 and Security Officer #2. Security Officer #1 was in the doorway attempting to leave. The patient yelled at Security Officer #1, "Hey, tall guy, I need to talk to you." RN #2 turned and heard the patient say he/she was sorry for his/her behavior in the ED. Security Officer #1 told the patient he/she didn't do anything wrong by him. All of a sudden, the patient stood up on the bed and took off his/her scrub top. Security Officer #1 told the patient they didn't do those types of searches. The patient then lunged at the officer and the officer pushed back. Security Officer #1 lost his balance and fell to the floor. The patient jumped on top of him and started hitting the officer in the head. The nurse stated everything happened so fast and then Security Officer #2 came into the seclusion room and got the patient off Security Officer #1. The patient started hitting Security Officer #2. Then the patient charged at RN #2 and hit him in the face. The officers had time to recover and pushed the patient into the Ante room. Patient #1 was still on his/her feet at that time. Officer #1 was trying to hold the patient, but the patient was swinging his/her arms uncontrollably. Officer #1 got behind the patient and told the nurse to hit the patient. RN #2 stated he put his arm out and made contact with the patient's face. The patient and Officer #1 fell onto the floor of the Ante Room. The officer took the patient down. The officer had his body over the patient's and yelled to call a Code Man and Police. That is when the patient said, "I'm done", "I'm done." The nurse stated he looked at the patient and Officer #1 and the patient was not fighting and was not bleeding. He stated he was rubbing his jaw where he had been hit when RN #1 opened the door to the Ante Room and yelled. "You all can't do that." He looked up and saw Security Officer #1 hitting the patient in the face with his closed fist. Officer #2 yelled at that officer, "Man stop", "Man stop." That is when RN #2 saw blood coming from the patient's face. This nurse denied he hit the patient with his fist or opened hand when the patient stated he/she was done.

Continued interview with RN #2 revealed he had never encountered a situation like that before and he was afraid. He stated there was no time to de-escalate the situation. He stated he had CSM training and he thought they went over a few specific holds, but he froze when t

Based on interviews, record review, and review of the facility's policies, and staff training records, it was determined the facility failed to ensure the nursing staff were properly trained to control a crisis situation for one (1) of twelve (12) sampled patients. Patient #1 was admitted to the Psychiatric Unit and placed in a closed seclusion room on 02/06/16 after evaluation in the Emergency Department (ED). The ED listed the chief complaint to be the patient was delusional with hallucinations. A drug screen was performed and the patient tested positive for amphetamine and marijuana (THC). A seventy-two (72) hour hold was obtained for treatment. Once the patient was admitted to the Psychiatric Unit, the patient became aggressive and violent with the staff. The patient attacked two Security Officers and a nurse. During the altercation, Security Officer #1 and Registered Nurse (RN) #2 were witnessed to strike the patient in the face several times with a closed fist. The patient sustained a fractured nose and laceration to the forehead that required sutures.

In addition, the facility failed to implement appropriate Crisis Situation Management (CSM) techniques and found the staff involved in the altercation with Patient #1 had not been properly trained. Interview with RN #2, on 02/18/16 at 11:05 AM, revealed the nurse had only worked in the Psychiatric Unit for six (6) months and felt he had not received adequate training for this type of violent situation and he was afraid. Although the nurse had received Crisis Situation Management (CSM) training, he had not implemented any of those interventions due to fear. The nurse had received abuse training; however, the training did not include employee abuse of a patient or how to report that. The facility failed to ensure the nurse obtained the skills required in high-stress situations.

Refer to A 0397

Based on interviews, record review, and review of facility policies, and staff training records it was determined the facility failed to ensure the nursing staff were properly trained to control a crisis situation for one (1) of twelve (12) sampled patients. Patient #1 was admitted to the Psychiatric Unit and placed in a closed seclusion room on 02/06/16 after evaluation in the Emergency Department (ED). The ED listed the chief complaint to be the patient was delusional with hallucinations. A drug screen was performed and the patient tested positive for amphetamine and marijuana (THC). A seventy-two (72) hour hold was obtained for treatment. Once the patient was admitted to the Psychiatric Unit, the patient became aggressive and violent with the staff. The patient attacked two Security Officers and a nurse. During the altercation, Security Officer #1 and Registered Nurse (RN) #2 were witnessed to strike the patient in the face several times with a closed fist. The patient sustained a fractured nose and laceration to the forehead that required sutures.

In addition, the facility failed to implement appropriate Crisis Situation Management (CSM) techniques and failed to report the alleged abuse to the appropriate State Agency and protect the patient from further abuse.

The findings include:

Review of the Nursing Organizational Chart for the Psychiatric Unit, revealed a Director of Services, Manager, Registered Nurses, Licensed Practice Nurse, and Mental Health Technician. Review of the facility's Organizational Chart revealed the Chief Nursing Officer (CNO) provided oversight to the unit.

Review of the Assault or Violent Behavior Policy, revised 10/26/15, revealed the policy was created specific for the Psychiatric Unit. The purpose was to ensure nursing was knowledgeable of behavior indicating potentially dangerous situations. The policy applied to all trained care providers, Psychiatric Unit staff, and Security Department staff. Stage I of the policy instructed staff to be alert to patients posing a higher risk of violent behaviors that included paranoia, inability to concentrate, increased voice volume, substance withdrawal, and psychosis-auditory or visual hallucinations. The key point was to notify the physician of escalating behaviors. Stage II was to call a "Code Man." Staff members participating in a "Code Man" are well trained in body mechanics and methods of holding a struggling patient without causing injury; Maintaining a comfortable distance (beyond the reach of hands/feet) from the patient; Facing the patient and maintaining an exit at your back; Only one person should talk with the patient; A staff member would be assigned to restrain each limb. When a patient's out of control state is acknowledged, tell the patient the staff are prepared to maintain control of him/her until they regain self-control. Tell the patient what you want them to do. Use the least amount of force necessary. Try to appear calm and in control. Do not show anger. If physical restraints are used, move without hesitation in an organized manner restraining all limbs. Explain to the patient that control was being maintained for them until self-control could be restored. Document clearly the mental status of the patient and threat of danger posed for themselves or others. Document interventions attempted to de-escalate patient, but were unsuccessful. If there were injury to the patient, staffs, or visitor, fill out an incident report.

Review of the facility's Code Man Policy, revised March 2011, revealed the purpose of the policy was to recruit assistance in preventing a non-armed, agitated, confused, and/or combative person from causing injury to self or others. Crisis Situation Management (CSM) training was provided for responders from the Security Department, Emergency Department, Plant Engineering Department, and designated staff from Environmental Services. Staff responding from other departments (Nursing and Transport) respond for manpower purposes (i.e. assist with physical control of combative person) under direct supervision of CSM trained personnel. Available Security personnel and trained CSM personnel respond to the announced location as quickly and safely as possible. If the situation is determined to be a medical crisis, nursing staff direct the actions of the responders, if the situation becomes threatening to staff, Security directs the action of the responders. In the event injury occurred to the patient, staff, or visitor, a reportable event form was to be completed. Employees are sent to the ED or Employee Health.

Review of Patient #1's clinical record revealed the patient was brought to the Emergency Department (ED), on 02/06/16 at 4:41 PM via the police. According to the ED physician's clinical report the police had found the patient wandering in the street barefoot and acting incoherent. The patient was making statements about being Jesus and exhibited unusual behavior. The chief complaint listed was withdrawn, delusional and hallucinations which had started the night before. The physician documented the patient's symptoms were described as severe. A drug screen was performed and the patient tested positive for amphetamine and marijuana (THC).

Review of the History and Physical, dated 02/07/16, revealed the patient was admitted to the Psych Unit on a seventy-two (72) hour hold when in the ED the patient was noted to be psychotic, very paranoid and attempted to leave the ED. Upon admission to the Psych Unit, the patient appeared to be very apprehensive. The physician ordered medication that included Haldol, Benadryl and Ativan. The patient accepted the medications. Suddenly, the patient became agitated and aggressive and began kicking, punching, and fighting the security officers. During this encounter, the patient was injured, that included forehead laceration and nose bleed. A Computerized Tomography (CT) scan revealed the patient sustained a nose fracture of the right nasal bone and required sutures for the laceration to the forehead. The attending physician interviewed the patient the next day (02/07/16) and the patient said he/she remembered bits and pieces of what happened to him/her. The patient told the physician he/she experienced visual and auditory hallucinations and felt very scared and apprehensive. The physician documented the patient's insight, judgment, and impulse control was significantly impaired. Diagnostic impression was severe drug use of amphetamine and marijuana and substance-induced psychosis.

Review of the Hospitalist Consult documentation (on 02/07/16) to evaluate Patient #1's injuries after the altercation with the security officers, revealed jagged laceration to the forehead with edema and tenderness. In addition, the nasal bones were assessed to be swollen into the bilateral super maxillary soft tissue. Contusions were noted on the left mid-calf and right posterior elbow. The Hospitalist documented the patient had multiple abrasions and contusions. He requested the patient's laceration to the forehead be treated in the ED.
Review of the ED records revealed physical restraints were applied on 02/06/16 at 6:10 PM, due to the patient bolting out of the ED room. The local police were in the ED (for another reason) and assisted the patient back to the ED bed. The reason for the physical restraints was the patient exhibited violent behavior including imminent risk of harm to self or others. Four-point restraints were applied. The one hour face to face restraint assessment was performed at 7:55 PM and documented the patient was agitated and confused.

Review of the nursing admission note, dated 02/06/16, revealed Patient #1 was admitted to the Psychiatric Unit at 8:45 PM for an involuntary seventy-two (72) hour hold with a diagnosis of Drug Induced Psychosis. Report from the ED nurse stated the patient had a history of Psychosis and Substance Abuse. The nurse reported the patient's eyes were dilated and the drug screen test was positive for amphetamine and marijuana. The nurse documented the patient had bolted out of the exam room, but was returned and placed in physical restraints. The patient arrived on the Psychiatric Unit in a wheelchair accompanied by two Security Officers. The patient was taken to the Seclusion Room for assessment. The patient initially resisted moving from the wheelchair to the bed but did with several directions and reassurance from staff. The patient was religiously preoccupied stating the nurse was the devil and asked that staff kill him/her because he/she needed to die for them. Due to the patient's psychotic agitated state, medication was ordered and admistered. The patient was given Haldol 5 mg (1), Benadryl 50mg (1), and Ativan 2 mg (1) via mouth. The patient took the medication with some hesitation at 9:50 PM. The patient was placed in seclusion due to the agitation and psychosis. The nurse left the seclusion room then returned to perform vital signs and a physical assessment. The door to the Seclusion Room had been locked with both Security Officers present in the Transition (Ante) Room. The patient was cooperative at that time. RN #1 returned to the nurses' station leaving RN #2 and the two Security Officers in the seclusion room with the patient. While at the nurses' station, RN #1 saw the patient stand up on the bed from the monitors at the Nurses' Station. The nurse documented she went to the Seclusion Room to assess the situation. She found one Security Officer struggling with the patient on the floor. A Code Man was called due to out of control and aggressive behaviors. The patient was placed back into seclusion with one to one staff monitoring.

Interview with the Director of Risk Management, on 02/17/16 at 12:36 PM, revealed the report given to him indicated the patient had become extremely violent and had injured two Security Officers and RN #2. The report revealed the patient had sustained injury, but indicated the injuries were sustained during the struggle with staff. The report stated the patient had been struck in the act of trying to restrain the patient. The report stated it took three (3) big men to contain the patient. The House Manager had reported to him the concern was the patient getting out of hand. The patient was seen by a Hospitalist to assess the patient's injuries. The Hospitalist ordered a CT scan that revealed a nasal fracture and ordered for the patient to be seen in the ED for the laceration to the forehead that required sutures. A psychiatric consult was ordered for a possible transfer to another psychiatric hospital. The Risk Manager stated it was not until he read the written statements that he realized there was an allegation of abuse. He stated he then interviewed the staff and RN #1 stated she saw Security Officer #1 strike the patient in the face with his fist. Interview with Security Officer #2 revealed the patient was struck in the face by Security Officer #1 and RN #2. Both employees were suspended at that point. He said RN #1 had reported what she witnessed to the House Manager but he failed to inform the Administrator On-Call (Chief Medical Officer) of the alleged abuse. The alleged abuse occurred on 02/06/16 at 9:00 PM in the Psychiatric Unit. The patient had been discharged from the facility on 02/10/16.

Interview with the Director of the Psychiatric Unit, on 2/17/16 at 1:21 PM, revealed she was not working the night of the incident. She received a text from the Psychiatric Unit Manager stating there was an incident of assault on the unit. She stated there was a camera in the seclusion room, it did not record, but was on the monitor at the Nurses' station. She stated two nurses were working the night of the incident, RN #1 was the patient's primary nurse and RN #2 was assisting. The doors to the seclusion room were locked. It was reported to her RN #1 had observed the patient standing up on the bed on the monitors at the Nurses' station. The nurse then went to assess the situation. Review of the Director's phone text revealed she received the text from the Unit Manager at 10:27 PM on 02/06/16. Review of the text revealed a report of an assault on the unit and that she would discuss the matter on Monday, 02/08/16. The Director stated she met with the Unit Manager on 02/08/16 to discuss the incident. The Unit Manager told the Director she had written statements from the staff. She spoke with the Chief Nursing Officer (CNO) on Monday (02/08/16) and filled her in on the details. She met with the Director of Risk Management on Tuesday regarding the concerns about this case.

Interview with Security Officer #2, on 02/17/16 at 3:01 PM, revealed he had been rehired to work at the facility a little over a year ago. He stated the night of the incident he escorted the patient from the ED to the Psych Unit. He stated it was the facility's policy to have two security officers to escort a patient to the Psych Unit. He stated the patient was put into the seclusion room. The patient cooperated with the nurse when she assessed the patient and gave him/her medication. He stated the nurses left and went to the Nurses' station and the seclusion room door was locked. Security Officer #1 had walked to the Nurses' station to get the wand to detect metal. The Security Officers use the device to search for knives and other sharp devices. The officer found none. The patient was dressed in paper scrubs with the patient's street clothing removed in the ED per protocol. Once the patient had been searched, the nurses left and he went into the Ante room (small entrance room before entrance to the isolation room). That left Security Officer #1 alone in the seclusion room with the patient. When he left the room the patient was laying on the bed not speaking. Very quickly the patient jump up on top of the bed and said, "You come here." He was pointing to Security Officer #1. The patient started ripping off the paper top and Security Officer #1 told the patient he/she didn't have to take off his/her shirt. The patient then said, "You are not going anywhere." The patient was standing on the bed. Security Officer #1 pushed the patient off the bed to the wall. The patient began swinging his/her fists and trying to hit the officer. He went back into the seclusion room and observed Security Officer #1 fall onto the floor with the patient on top of him. The patient was hitting Officer #1 on the head. He lifted the patient off the other officer and the patient started hitting him in the face. The patient hit Security Officer #2 in the lip and jaw twice. He stated he pushed the patient off him and at the same time RN #2 came back into the room and the patient went after him. The patient ran from the seclusion room into the Ante room. By that time, Security Officer #1 was back on his feet and went after the patient. He pushed the patient into a corner of the Ante room and placed his body over the patient's to hold him/her down. According to Security Officer #2, he called a "Code Man", but before the team could arrive to help, Security Officer #1 placed the patient into a head lock and punched the patient in the face with his fist. The officer then told RN #2 to hit the patient in the face and he did. The patient began bleeding from the face. He stated he didn't say anything about what he saw at that time. Then RN #1 came to the door and brought restraints. However, there were only three (3) restraints and they needed four (4). He left the room to search for another limb restraint. The Code Man team had responded by that time. When he returned with the fourth restraint, the patient was on the bed in the seclusion room, cooperative, bleeding from the face. The patient refused treatment for the injuries at that time so the staff locked the door and left the patient. According to Security Office #2, he did not know if what he saw was abuse or not. He stated he had not reported it as abuse. He had training on abuse, but could not recall when. He stated he should have reported the abuse to the Security Manager. He recalled Security Officer #1 worked the next day and he stated he had no training in CSM techniques.

Review of Security Officer #2's written statement revealed the same details the officer stated in his interview. He had witnessed Security Officer #1 place Patient #1 in a head hold and punched the patient in the face with his fist several times. He also wrote he witnessed RN #2 hit the patient in the face with his fist.

Interview with RN #2, on 02/18/16 at 11:05 AM, revealed he had only worked in the Psych Unit since August 2015. He was only helping RN #1 that night because Patient #1 was not assigned to him. When the patient was admitted to the unit he/she was placed in the seclusion room. The patient was delusional calling RN #1 the devil and the patient was Jesus Christ and he/she needed to sacrifice his/her life for their sins and save man-kind. The patient was given medications to calm down. He stated the patient was left alone in the locked seclusion room for a short while. The patient was lying on the bed quietly. The two Security Officers were in the Ante Room just outside the seclusion room. Security Officer #1 went to the Nurses' Station to get the wand. The nurses and Security Officer #1 walked back to the seclusion room opened the door and everyone went in. The patient was resistive taking the medication at first, but then took the medication. The patient was calm. RN #1 left the seclusion room first followed by RN #2 and Security Officer #2. Security Officer #1 was in the doorway attempting to leave. The patient yelled at Security Officer #1, "Hey, tall guy, I need to talk to you." He turned and heard the patient say he/she was sorry for his/her behavior in the ED. Security Officer #1 told the patient he/she didn't do anything wrong by him. According to RN #2, all of a sudden, the patient stood up on the bed and took off his/her scrub top. Security Officer #1 told the patient we didn't do those types of searches. The patient then lunged at the officer and the officer pushed back. Security Officer #1 lost his balance and fell to the floor. The patient jumped on top of him and started hitting the officer in the head. The nurse stated everything happened so fast and then Security Officer #2 came into the seclusion room and got the patient off Security Officer #1. The patient started hitting Security Officer #2. Then the patient charged at RN #2 and hit him in the face. The officers had time to recover and pushed the patient into the Ante room. Patient #1 was still on his/her feet at that time. Officer #1 was trying to hold the patient, but the patient was swinging his/her arms uncontrollably. Officer #1 got behind the patient and told the nurse to hit the patient. RN #2 stated he put his arm out and made contact with the patient's face. The patient and Officer #1 fell onto the floor of the Ante Room. The officer took the patient down. The officer had his body over the patient's and yelled to call a Code Man and Police. That is when the patient said, "I'm done", "I'm done." The nurse stated he looked at the patient and Officer #1 and the patient was not fighting and was not bleeding. He stated he was rubbing his jaw where he had been hit when RN #1 opened the door to the Ante Room and yelled. "You all can't do that." He looked up and saw Security Officer #1 hitting the patient in the face with his closed fist. Officer #2 yelled at that officer, "Man stop", "Man stop." That was when RN #2 saw blood coming from the patient's face. This nurse denied he hit the patient with his fist but with a opened hand.

Continued interview with RN #2 revealed he had never encountered a situation like this before and he was afraid. He stated there was no time to de-escalate the situation. He stated he had CSM training and he thought they went over a few specific holds, but he froze when the patient hit him and he was afraid. He admitted he had struck the patient two (2) times, but it was when the patient was still standing and he was trying to stop the patient and help Officer #1 bring the patient down. The patient was quiet after that when the Code Man team responded. He got hit in the head and couldn't think straight. He stated he finished working his shift. He took the patient down to X-Ray and the ED for sutures. The patient was cooperative with no further outbursts. The nurse stated he had received training on abuse and how to report. He stated when the patient stated they give up and quit fighting, and when the officer hit the patient in the face that was abuse. The nurse stated he did not think he received adequate training to deal with a violent situation such as this one. When Security Officer #1 hit the patient after he/she said they were done and quit fighting, he said he would consider that abuse.

Review of RN #2's written statement, dated 02/06/16, revealed the patient was agitated and taking about being Jesus and needed to be killed and sacrificed for their sins. The nurse documented the same details as the other staff regarding the patient receiving medication and was checked with a wand without any problems. The patient was lying on the bed at that time. He stated suddenly the patient stood on the bed and took off the scrub top. Security Officer #1 told the patient he/she didn't need to remove the scrub top because he did not need to do that kind of search and asked the patient to get down from the bed. The patient went into a rage, and lunged from the bed at Security Officer #1. The patient was swinging wildly and the officer was trying to get the patient to the ground. There was a struggle and the officer got the patient down on the floor but the patient slipped behind the officer and started hitting him on the head. Security Officer #2 flanked the patient from the right side of the bed. Security Officer #1 was down and dazed. The patient then started hitting Security Officer #2. The patient then charged RN #2 who was blocking the doorway to the Ante Room. The patient hit the nurse two times on the left side of the head. The nurse documented he was a little dazed. At that time, both Security Officers had recovered and charged the patient. The patient was taken down onto the floor of the transition room. The patient continued to resist, battling to get out from under the officer. The nurse documented the patient was on the verge of exhaustion. He looked away to check his injuries. A few seconds later, RN #1 was heard to say, "You all can't be doing that." Additional staff had arrived for support. RN #2 documented when he looked at the patient, the patient was down, exhausted and bleeding. Security Officer #1 was still on top of the patient. RN #2 left the room at that time.

Observation of the Patient #1, on 02/18/16 at 12:10 PM, revealed the patient had been brought back to the ED via the police and tested positive for drug use. Observation revealed the patient was lying on a stretcher in an ED room with one-to-one supervision provided by the ED staff. The patient had on paper scrubs and was awake. The patient agreed to speak with this writer and a DCBS worker.

Interview with Patient #1, on 02/18/16 at 12:10 PM, revealed he/she could not recall all the details of the incident that occurred on 02/06/16. The patient stated he/she did not normally act like that and apologized to them. The patient stated he/she thought they were going to hurt him/her. The patient recalled he/she had rushed at the Security Officer and had jumped on the bed. The patient stated the staff humbled him/her. When asked what the patient meant by that statement, the patient stated they hit him/her in the face with their fists. The patient stated he/she recalled the officer told someone to come in there and hit the patient and they did. The patient did not know who had hit him/her. The patient stated he/she got hit six (6) to seven (7) times,but couldn't recall all the details. The patient stated the big guy (Security Officer #1) hit him/her and then told another person to hit the patient. The patient stated it had hurt and he/she was afraid that was why he/she gave up because he/she wanted it to stop.

Review of the facility's investigation revealed the House Manager reported the alleged abuse to the Risk Manager on 02/08/16. Written statements were reviewed by the Director of Risk Management. Staff interviews were conducted on 02/08/16 and 02/09/16. Security Officer #2's interview revealed Security Officer #1 had placed the patient in a headlock and struck him/her multiple times in the face. He alleged RN #2 had struck the patient at least twice in the face. The officer told him he had not had any training in de-escalation since he was rehired.

RN #2 was interview by Risk Management, on 02/12/16 at 8:30 AM, where he acknowledged he may have thrown a punch when he was initially struck by the patient. RN #2 was placed on administrative leave until further notice.

Review of the facility's training material for Crisis Situation Management (CSM) revealed a power point presentation. The purpose of the training was to provide instruction on the safe management of individuals or visitors that have lost control of themselves through the use of verbal de-escalation techniques and when necessary physical intervention. The training stated regardless of what the staff thought or believed, the individual is "living" what they think is reality. The key points instructed the staff not to use abusive, obscene, derogatory, or profane language with the individual. Under crisis definition, the training described an emotionally significant event or radical change of status in a person's life. The training provided active listening skills and other communication skills. The training discussed when an individual displayed aggressive or combative behaviors that arose from a medical or psychiatric condition (including intoxication) and was at risk for harm of self or others; however, there were no interventions listed for staff to implement. The next section discussed physical restraints and seclusion. The training then went to the topic of areas of vulnerability of the individual that included the head. Trauma to the nose can cause respiratory problems and/or trauma to the brain. Under gaining physical control of an individual "acting out" revealed there must be staff that had training in CSM. The team leader (most of the time security staff) would direct staff to control which limb of the body to control. Only one person should talk at a time. The training discussed how to apply physical restraints. The next section discussed staff self-defense ensuring staff could react, if needed, to physical attacks. "You react the way you are trained." When dealing with an agitated person, keep yourself at least six (6) feet away when possible. The most vulnerable position is directly in front of the person. Keep eyes on the person. The training detailed blocking/deflecting techniques that included retreating with hands in front of them. The techniques included sweeping kicks, pushing off from the attacker, wrist grab, and release from a choke hold. There was no training on CSM holds to control the situation. The CSM training (formerly Crisis Prevention Interventions, CPI) is required every two (2) years. A post-test was given. A CSM checklist, revised November 2015) that included demonstration of defensive skills and was required for successful completion of the CSM program.

Review of RN #2's personnel record revealed the nurse transferred to the Psych Unit on 07/26/15. The nurse was in orientation training from 07/30/15 - 09/03/15. The nurse received CSM training on 11/18/15 and abuse training on 04/19/15 prior to his transfer. Review of the job description signed by RN #2 and dated 12/25/15, revealed the job required working in a high-stress situation and the unit specific essential function was a demonstration of knowledge regarding psychotherapuetic interventions.

Interview with RN #2, on 02/18/16 at 11:05 AM, revealed the nurse had only worked in the Psychiatric Unit for six (6) months and felt he had not received adequate training for this type of violent situation and he was afraid. Although the nurse had received Crisis Situation Management (CSM) training, he had not implemented any of those interventions due to fear.