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Based on review of records, observation of video tape, and interviews, the facility failed to ensure processes were developed with effective implementation of those processes that protected the rights of patients, as shown by staff not adequately intervening during a defiant and violent patient free-for-all uprising event on the evening of 9/10/22.

More specifically, the facility failed to

A. Protect patient rights to a safe environment for 19 of 19 patients (Patients
#A, B, C, D, E, F, G, H, I, J, K, L, M, N, O, P, Q, R, R, & #S), who were all
present on the facility's Sunrise unit during the event;

B. Failed to protect 13 of 19 patients from an environment of fear (Patients #I, J, K,
L, M, N, O, P, Q, R, S, T, & U);

C. Failed to ensure implementation of their own policy and procedure to proactively
prevent prevent patients from violently taking control over an adolescent unit.

This was evidenced by:

a. There were 19 patients present in facility's Sunrise unit, which housed both male and female adolescent patients on the evening of 9/10/22. Eight of these patients (Patients #A, B, C, D, E, F, G, & H) became involved in a defiant uprising and took control over the unit. Nursing staff failed to intervene and did not control the patients. Other staff did not adequately intervene to control patients. The uprising ended with police intervention over 15 minutes later from when the event began.

The patients: jumped into the nurse's station throwing items onto floor which included chairs, papers, files, a cart on wheels; used bodies and feet attempting to break through unit's entry/egress doors; attempted to break down door of dayroom which was protecting several patients avoiding the violence; punched and ripped off hand sanitizer dispenser from wall; kicked-in and broke fire extinguisher door which allowed access to a large metal fire extinguisher; banged a large metal fire extinguisher against dayroom door attempting to break into locked dayroom which housed patients who did not participate in the uprising; sprayed the fire extinguisher in the air and onto other patients in unit. The fire retardant remained suspended in air and also accumulated all over the unit floor.


b. There were 13 patients who were not directly involved in the defiant outburst (Patients #I, J, K, L, M, N, O, P, Q, R, S, T, & U). These patients were subjected to riotous violent behavior which could have resulted in serious injury or death. Most of these patients who were not involved were hiding in a locked dayroom. The riotous patients attempted numerous times to get to this locked dayroom by trying to break down the door during by kicking, slamming bodies, and banging a fire extinguisher against the door. All the patients were witness to violent behavior, including; yelling and screaming by patients and police, entire unit being 'trashed', fire retardant both in the air and on the floor; police handcuffing nine patients, two of whom were physically and verbally defiant against police. Two patients sustained injuries and were sent to the hospital emergency room during event via EMS ambulance; one for chest pain & shortness of breath (Patient #E) and another for an arm injury (Patient #F). In addition, three patients discharged Against Medical Advice (AMA) the following day on 9/11/22 not completing treatment, as a result of the event.

C. Patient #A had a history of jumping over the nurse's station desk and into the nurse's station on at least three separate occasions previous to the event on the evening of 9/10/22. There was no change to the patient's care plan including any precaution level changes to address this behavior. Patient #A was identified by Risk Manager Staff #A as being the possible 'ring leader' during the outburst riotous event.

Cross reference FED-A0144- PATIENT RIGHTS: CARE IN A SAFE ENVIRONMENT-CFR 482.13(c)(2)

Based on review of records, observation of video tape and interviews, the facility failed to provide a safe environment for 19 of 19 patients (Patients #A, B, C, D, E, F, G, H, I, J, K, L, M, N, O, P, Q, R, R, & S) as shown by the facility's staff failure to intervene adequately when eight patients (Patients #A, B, C, D, E, F, G, & H) became out of control and staged a defiant uprising that took over the entire unit (Sunrise unit).

Findings included:


In an interview on 9/16/22 at 2:00 pm, Risk Manager (RM)- Staff #1 stated that on 9/10/22 at 8:43 pm in the facility's Sunrise Unit (an adolescent unit house both males and females), there appeared to be a planned event where some patients revolted and became out of control. They threw papers and knocked over chairs in the nurse's station and threw papers. Then they kicked-in the door housing of a fire extinguisher and tried to break into a locked Group room where several patients were sequestered away from the commotion. RN-Staff #8 called a "Code 100" (behavioral emergency) because the three staff on the unit could not control the patients. Police arrived soon after and were able to take care of the situation. They had to handcuff nine patients. Staff #1 added that two patients were brought to the hospital via ambulance after the event was over: Patient #E due to chest pain and shortness of breath caused by inhalation of fire extinguisher contents and Patient #F due to having her arm injured from being retrained by police.


Review of the facility's video-taped footage showed the following: on 9/10/22 at 8:43 pm, the incident began when two patients in the large open common dayroom in front of nurse's station in the Sunrise Unit appeared to be arguing.

Immediately following this, mayhem clearly ensued: There were eight patients involved. They jumped over the nurse's station and threw papers, files, knocked over chairs and a cart. PCA-Staff #10 was seen opening a Group dayroom door and sequestered most of the patients inside the room. These patients were apparently not involved in the uprising. Several of the involved patients were seen trying to break down the door to get to inside this locked room. They had made several attempts by pushing and banging against the door in an effort to breach it. They were also seen kicking and pushing against the entry/egress doors to get out of the unit. This was repeated several times during the event.

During the event, staff were seen standing and watching the patients. RN-Staff #8 and RN-Staff #9 were seen standing behind the nurses's station and not moving while patients were jumping into the nurse's station. There were no arm gestures or other apparent evidence the nurses attempted to control the situation. Three more staff members later appeared on the unit but also did not control or stop the patient outburst.

Patient #G was seen pushing RN-Staff #11. Another patient was seen punching and removing from the wall a hand sanitizer dispenser. Patients involved, through repeated kicking attempts, broke the door-housing of a fire extinguisher and were able to access the fire extinguisher, which they used to bang on the locked dayroom door protecting the patients who were not involved.

Patient #F then sprayed the fire extinguisher in the hall into the air, the floor, and onto other patients. The unit filled with yellow fire retardant which stayed suspended in the air throughout and after the event.

Police were then seen on the unit at 9:01. There were a total of seven who appeared. They were seen gathering and controlling the patients. The police handcuffed nine patients total; eight who were involved and one who was not involved. This patient who was not involved was not locked in the protected dayroom.

Emergency Medical Services (EMS) were seen at 9:35 pm.

Record review during survey of Patient # E's clinical chart showed she was sent to the hospital via EMS ambulance during the event for chest pain & shortness of breath. This was the result of breathing the fire retardant chemicals from the fire extinguisher sprayed during the event. She was medically cleared and sent back to facility.

Record review during survey of Patient #F's clinical chart showed she was also sent to the hospital via EMS ambulance during the event for arm pain. This was the result of having a physical altercation with police during the event. It was found that a birth control implant was irritated. The patient was treated and released, then sent back to the facility.

Record review of the clinical charts of Patient #I, #J, and #K showed all three had discharged Against Medical Advice on 9/11/22. The reason these three did not want to complete treatment at the facility was due to fear and trauma from the event that occurred 9/10/22.





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Based on observation, record review and interviews the facility failed to ensure the effective implementation of policies and procedures that
promoted care in a safe setting for 19 of 19 adolescent unit patients (Patients A through S). Specifically, the facility failed to ensure that Registered nurses #8, #9, #11 and #13 followed facility procedures to gain control of a violent patient free-for-all that caused injury, duress and hospitalization to fellow patients.

The findings include:

Policy:
A) Levels of Observation and Precautions (10603895) Last Approved 01/22

Policy:
The nursing staff and medical providers will assess for risk level and make level of observation and precaution recommendations based on the risk level assessment findings and patient behaviors.
It is critical that patient observation level and precautions are documented on the Patient Observation Record and communicated to team members.

PURPOSE:
To ensure there is clear differentiation stay on the basis of past behavior, present situation, between patients need at different levels of risk are present. The levels of observation and precautions are identified based on the risk assessment as well as by patient behavior.

Procedure:
1. The registered nurse and Physician determine the level of risk associated with each new admission and throughout their hospital stay on the basis of past behavior, present situation, and current mental status.

Policy:
B) Seclusion and Restraint (11954000) Last Approved 07/22

Purpose:
To provide guidelines for the use of seclusion and/or restraints at the hospital and clinics.

Procedures:

RN:
Assess the patient's behavior on a regular basis to determine any imminent risk of the patient physically harm self, staff for others.
Nursing Staff:
When the patient is present in behaviors that are such that the present an imminent danger to the patient or others, staff utilized the following less restrictive, one physical interventions:
Separate the patient from the group or community.
Redirect the patient's focus.
Engage in 1:1 conversation or activity to allow the patient the opportunity to safely expressed feelings.
Employ verbal de-escalation.
Take the patient to his/her room with staff present.
Over the patient the opportunity to use the quiet room to decrease stimuli and regain control.
Administer medication as ordered by the Physician to help the patient more effectively function in his/her environment.
Document the alternatives attempted or the rationale for not using alternatives.

Annual Staff Training (On-line Modules by Springstone)
A) Seclusion and Restraint

Nonphysical interventions should be the preferred method of intervention.
It is important to make every effort to use and non-physical intervention in order to prevent further traumatization of patients by staff.

Alternative Approaches:
1)Therapeutic touch -staff using a light touch to direct an individual to another area.
2) Physical escort gently holding the patient's arm to escort them to a desired location.
3)Time out- patient is provided an opportunity to calm down away from immediate stressors. This can take place in a patient's bedroom or seclusion room. Either staff or patients can initiate this. All patient and staff to determine when patient can return to the milieu.

Emergency crisis:
Violent and aggressive advance requiring immediate interventions.

Milieu Management Training (On-line Modules by Springstone)
We can make a difference by:
Taking ownership in our job duties and responsibilities.
Being proactive to PREVENT incidents.
Managing and monitoring our milieu vs. letting it control us.
Working as a TEAM.
COMMUNICATING.
Taking part of the solution instead of the issue.
A taking the initiative to help things work BETTER.
Being HUMBLE and KIND and treat everyone with RESPECT.

Situational Awareness Training (On-line Modules by Springstone)
1.14 Importance of Situational Awareness
Having proper situational awareness is directly quart correlated to patient safety.
The patient's behavior may continue to escalate if not address by due or one of your coworkers.
Many of the patients in our care of very vulnerable positions struggling with mental health and substance abuse issues which may lead to an even higher potential of escalated behaviors and acting out.

Review of Adolescent Unit film from 9/10/22 on 9/16/22 at 1430 with two surveyors and staff #1 Risk Manager.

Film revealed five patients jumping onto the nursing station desk and into the station area. Later one other patient also entered. The patients in he nursing area began swiping papers files and supplies of the nursing desk onto the floor. They tipped over a two-tiered cart containing supplies and miscellaneous and storage shares into the day room. Other patients were observed tearing a hand sanitizer dispenser off the wall and repeatedly kicking the fire extinguisher casing on the wall. Various patients to turns and joined together to tear the fire metal extinguisher door and metal hinges off the wall to gain access to the fire extinguisher.
The bottom portion of the fire extinguisher was used by several patients to unsuccessfully, attempt to break through the window of the group room door to gain access to that room where the PCA and other patients were hiding for safety. Other patients were running back and forth in the dayroom knocking over whatever was able to be knocked over.
During all this email nurse assigned to the unit staff #13 RN never moved from the far side of the nursing island in the nursing station. Male RN #9 was observed to pro his head in his hands with elbows on the nursing island watching the free-for-all. Male RN #9 was observed to take his cell phone out of his pocket and look at it but not to talk or text on it.
Both RN's (9 & 13) watched the patents destroy property and create havoc without ever pointing to stop, attempting to direct any patients to safety or making an attempt to end the free-for all until two other RN's arrived in response to the code. Male nurse #9 left the nursing station, walked to the group room door said something to the male patient pounding the door with the fire extinguisher then immediately turned around and returned to the nursing station. Moments later the extinguisher was user by a patient to spray other patients and the air turned white with its contents. Patients were observed coughing and running.

Code responder RN #11 moved between the group room hall and where the hall connected to the dayroom and was speaking to patients. Hold responder RN #9 was in the middle and far end of the dayroom speaking to patients and also was seen entering the nursing station speaking to the two RNs there and returning to the unit from the floor. The patients did not stop.

At no time during the free-for-all did the floor staff or code respondents utilize 1) Therapeutic touch 2) Physical escort, 3) Time out, emergency medication administration, seclusion or restraint. At no time during the free-for-all did the floor staff or code respondents point to chairs for the patient's to be seated in or direct them to rooms and other separate areas.

Approximately 15 minutes after the onset of seven police officers arrived and moments later an additional one officer arrived. Some patients were combat it with the police that the police easily gain control of the situation.
Eight patients were handcuffed one was placed on a gurney by EMS. Administrative personnel were noted arriving. Two patients were transported to the hospital for injury and held overnight.

Record Review

Patient #A was admitted 9/2/22 for so suicidal ideation with a plan. Diagnoses included anxiety, depression, oppositional/defiant disorder and bipolar disorder. Patient A was identified as the first to jump into the nursing station and the possible ringleader of the planned free-for-all. Therapy notes frequently documented patient #A did not attend group therapy.
All
9/3/22 @ 2045 nursing note: "Jumped the nursing station. While at the nursing station patient was throwing things on the floor and pacing back and for a period the patient jumped the other side and stood by the double door. After a few minutes patient jumped back into the nursing station an against darted to throw chair charts by the signs machine on the ground. Patient asked to stop behaviors she did not cooperate was staff. Patient danger to self and others. The restraint and directed to seclusion. Emergency medications administered
9/3/22 @ 2045 nursing note: "Jumped the nursing station. Breaking and throwing hand sanitizer holders, door tags, things behind the nursing station. Emergency meds given.

Record indicated no change to treatment plan, precautions or environment after these destructive incidents.

Interviews:

Interview

When interviewed on 09/16/22 at 1325 staff #1 Risk Manager stated, three patients discharged AMA that evening due to the incident and another left the next day.

Interview
When interviewed on 09/16/22 at 1530, Patient # G stated "they planned it. It was planned before that happened. We knew what was going to happen, but I don't know who planned it. I was the one with the fire extinguisher trying to bash down the group room door." The patient stated initially he had been taken to the group home by PCA #10 when patients began jumping into the nursing station area. He stated that patient #O and others in the group room, "were snitching" on who did what it and he did not like that. He stated, "Snitches get shot." He thought patient #O was going to assault him so he left the group room and joined the ruckus out of anger.

When asked what its staff do in response to patients jumping the nurse's station, grabbing files, and objects including chairs, ripping things off the walls, and he and others trying to smash with I and spraying others with the contents he responded "Nothing." Staff then said they had behind the desk by the medications. They didn't do anything; they didn't say anything. He added that "Nobody yelled at us, no takedowns or restraints. They just let it happen. It got out of hand and got scary.

He said male registered nurse # 8 came out from behind the nursing desk, briefly, said "calm down" and returned to the nursing station. He stated the female nurse never moved from the farthest corner only in the nursing station.

He added that the patients knew they took charge of the unit when they realized the staff were doing nothing to stop them.
Interview
When interviewed on 09/19/22 at 1320, staff # 6, Director of Clinical Services stated "it was such a surprise that could imagine it would happen." She stated after the event therapists #26, 27 and 29 "Processed" with patients who wanted to but no debriefing of patients occurred.