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Based on review of facility Patient Rights policy, review of facility video and investigation, record review, review of the Behavior Protocol, and interviews, it was determined the facility failed to protect and ensure patient rights for care in a safe setting were provide for one (1) of thirteen (13) sampled patients, Patient #6. Patient #6 sustained a raised area to the head and an abrasion to his/her upper lip in an incident with Behavioral Health Unit (BHU) Program Coordinator (PC) #1.

The findings include:

Review of the Welcome Guide for Patients and Visitors, no date, revealed the facility had a zero-tolerance policy for physical abuse, which included holding or restraining someone.

Review of the Program Coordinators job description, revised 08/30/2021, revealed functions included providing leadership and guidance to unit staff, assisted in providing leadership to maintain a safe environment for patients utilizing proactive techniques to de-escalate an individual.

Review of the facility's "Restraints and Seclusion" policy, reference number 600-0368, last reviewed 10/10/2023, revealed the facility was committed to providing a safe, secure environment.

Review of the Behavior Protocol, revised 07/03/2023, revealed when a patient was in Time-out, staff were to speak to patients in a calm manner and not to argue with patients.

Review of the 3 Lourdes Unit Handbook, (Patient #6's Unit) dated 04/2022, revealed the safety of all patients and staff was a priority. A patient could be encouraged to take a "self-time-out", which was not a consequence but an opportunity for the patient to remove themselves from the milieu (social environment) to practice coping skills, process with a staff member or have quiet time alone.

Review of the facility policy titled "Precaution Levels", reference number 11271004, reviewed 06/26/2022, revealed each patient would be assessed upon admission for behavioral indicators, using the established guidelines. Review of the guidelines for suicide precautions-level I (SP1) revealed the criteria was based on a history of passive suicidal ideation (SI), or SI with a plan that would not be feasible while hospitalized.


The facility admitted Patient #6 on 10/02/2023 from a group home. Admitting diagnoses included increased aggression of attacking peers and staff, and property destruction. Patient #6 denied suicidal ideation (SI), but staff reported threats to harm self prior to admission. Patient #6 endorsed previous suicide attempts by tying a hoodie around his/her neck. Patient #6 was assigned a Suicide Precaution level of one (1) (SP1) on admission.


Review of Physician orders dated 10/02/2023 revealed Patient #6 was assessed as SP1 on admission. Continued review of Physician orders revealed #6 remained SP1 during hospitalization.

Review of the facility's investigation revealed Leadership (includes the Unit director of Nursing, Chief Nursing Officer), reviewed the video footage, dated 10/25/2023, from the incident between Patient #6 and Program Coordinator (PC) #1. Additional review revealed that on 10/25/2023, Patient #6 was assessed and treated, notifications were made to Physician, Unit Manager, DCBS (Guardian), House Supervisor, Risk Management and Administrator on Call of the incident, and the allegation of abuse. Also, on 10/25/2023, Risk Management initiated the internal abuse protocol. This included reviewing the video footage of the incident, and interviewing Patient #6, RN(s) #1 and #2 and PC #1; Child Protective Services (CPS) was notified of the abuse allegation and the on-going internal investigation by Risk Management. Risk Management Report #3756675 was generated on 10/25/2023 at 3:38 PM.

Continued review revealed that on 10/26/2023 Leadership met to review the video footage, from which a deviation of a non-standard physical restraint was identified (the way PC #1 initiated the sitting cradle hold), the findings of the internal abuse investigation and consulted with the Regional Director of Quality. The decision was made to substantiate the abuse allegation on 10/26/2023. Leadership terminated PC #1 on 10/27/2023 due to gross misconduct.

Attempts to contact PC#1 were unsuccessful.

Review of the video footage (no audio) of the incident between Patient #6 and PC#1, dated 10/25/2023, by the State Survey Agency (SSA) Surveyor, with Lead Investigator #1, revealed that on 10/25/2023 at 8:05:54.835 AM, Patient #6 was escorted to 3 Lourdes (3L) Unit dayroom for a Time-out to calm self, by a staff member that was not able to be identified because of camera angles, for disruptive school behaviors. Patient #6 was wearing a tee-shirt and sweatpants.

Continued review revealed that at 8:06:10.210 AM, Patient #6 sat in his/her assigned seat in the dayroom. The sweatshirt was visible under the seat and Patient #6 started playing with the sweatshirt. At 8:06:34.885 AM, the staff member left the dayroom. Per Lead Investigator #1, PC #1 was out of the frame but was outside the door, able to keep eyes on Patient #6 while in the dayroom. This information could not be verified related to PC #1 not returning voice mail to return phone calls. Also, Lead Investigator #1 stated that Patient #6 was in the dayroom for Time-out because the quiet room was in use. Further review revealed that from 8:06:51 AM to 8:22:39.22 AM, Patient #6 became disruptive in the dayroom by playing with the sweatshirt, making a ball with it, and removing sweatpants (gym shorts underneath) to play with also. He/she was observed to be dancing and doing pinwheels around the room, throwing, and retrieving the shirt ball. Per Lead Investigator #1, Time-out did not begin until a patient was able to be calm.

Further review of the facility video footage revealed Patient #6 and PC #1 were observed at 8:22:39.221 AM to leave the dayroom. Patient #6 was carrying the shirt ball and sweatpants. At 8:22:55.778 AM, both were observed to enter the quiet room, and Patient #6 used the sweatshirt and pants to make a pillow and put him/herself on the bed, PC #1 was at the foot of the bed. Body language by PC #1 suggested he was speaking to Patient #6. Lead Investigator #1 stated that it would be at this point that PC #1 would have asked for the sweatshirt and pants because of ligature risk and Patient #6's history of suicidal ideation (SI). At this point, Patient #6 was observed to get up and stand to the right of the head of the bed. PC #1 moved to the left side of the bed. Further review revealed PC #1 stepped on the bed and Patient #6 moved to dead center of the bed, under the window.

Additional review of the video footage revealed that at 8:22:58.058 AM, PC #1 caught up with Patient #6 and his left hand was observed to contact the neck of Patient #6's tee-shirt.

At 8:22:59.709 AM, Patient #6 was observed to slap PC #1 and his (PC#1) head snap to the right side.

Continued review at 8:23:00.028 AM, revealed PC #1's open left hand came up face-level with Patient #6. Contact was unable to be verified at that time.

Additional review of the video revealed that at 8:23:00.440 AM, contact was made.

At 8:23:01.327 AM, PC #1 was observed to initiate a step-by-step transition of his right hand away from Patient #6's face to gain control of Patient #6's left forearm to be able to obtain control of Patient #6's right forearm with his (PC #1) left hand to initiate a standing cradle assist (an approved children's control position-medium hold).

At 8:23:05.364 AM, PC #1 transitioned patient #6 to a sitting cradle assist.

Further review of the video footage revealed that at 8:23:17.645 AM, two (2) additional nurses entered the room, assessed Patient #6 and the video ended.

While interviewing Registered Nurse (RN) #1, (Charge Nurse that day) on 11/02/2023, at 3:36 PM, she stated that she did not witness the incident; another patient called her attention to the incident, and she went to investigate. During continued interview, RN #1 stated she observed PC #1 to be transitioning Patient #6 to a sitting cradle hold. She stated she heard Patient #6 verbally contract for safety and he/she was released from the hold. She added that RN #2 had entered the room and assessed Patient #6 for injuries. As the interview continued, RN #1 stated RN #2 escorted Patient #6 to the nurses' station to treat Patient #6's injuries while she and the Unit Manager escorted PC #1 off the floor and to Nursing Services. RN #1 stated that at the time, Patient #6 did not formally state an allegation of abuse, that it was more like a casual statement that PC #1 had hit his/her head on the wall.

During an interview, on 11/07/2023, at 4:32 PM, with RN #2, he stated there were no additional witnesses to the incident. He stated he did not observe a "hoodie" in the room, only what he thought was two (2) sweatshirts. He continued the interview by stating that hoodies were not allowed on the Units at all, and patients were not allowed clothing that was not being worn, for ligature risk safety (Patient #6 had been admitted with a suicide precaution (SP) Level 1). RN #2 continued by stating that he had assessed Patient #6 in the room for injuries. He further stated that he observed a scant amount of blood on a front tooth of Patient #6. Continuing the interview, he stated Patient #6 had a split lip that was not actively bleeding and a raised area on his/her head. Treatment consisted of ice to the lip and Motrin. RN #2 stated he ensured appropriate notifications were made and that was the extent of his involvement.

While interviewing the Risk Manager (RM), on Wednesday, 11/08/2023, at 9:03 AM, he stated it was felt there was not a systemic/procedural failure for the incident, it was not an education failure; Program Coordinator (PC) #1 had made a conscious choice to handle the incident the way he did. The interview continued by the RM stating that PC#1 had received additional training for the Program Coordinator job, had been a former instructor for crisis prevention interventions (CPI) (teaches staff how to safely and effectively respond to individuals whose behavior is escalating). During the interview, the RM stated PC #1 had the tools to handle the incident but chose not to call for help when there was no crisis at that time. Patient #6 was in a contained environment with no chance of hurting him/herself or others at that time, PC #1 could have called for help to diffuse the situation.

On Wednesday, 11/08/2023, at 10:18 AM, the RM reported to the State Survey Agency (SSA) Surveyor that while he was being interviewed by the SSA Surveyor at 9:03 AM, he became aware there had been a Global Nurse Managers' meeting (scheduled every Wednesday) and one of the topics was a presentation given by the Quality Director regarding hands-on versus de-escalation.

On 11/08/2023, at 9:28 AM, while interviewing Quality Analyst/Lead Investigator #1 (LI #1), he stated that prior to working in the Risk Department, he had been a Program Coordinator (PC) and had trained PC #1, he knew PC #1 was well trained. LI #1 continued by stating it was determined through his investigation that it had been an individual failure and not a systemic failure.

Additionally, the completed investigation was then sent to the Quality Patient Safety (QPS) Committee for final decision and disposition. The core members of the group (also called Leadership) included the Director Nursing (DON) of the Unit, the Unit Manager (UM) of the Unit, Director of Quality and/or the Chief Executive Office, Chief Operating Officer, and the Chief Nursing Officer. Other individuals were added as necessary.

While interviewing the UM of 3 Lourdes (3L), (the unit Patient #6 was on), she stated that if an incident occurred on her Unit, she would be included in the QPS meeting. Regarding the incident involving Patient #6 and PC #1, she stated she was made aware of the incident while in the Global Nurse Manager meeting, she left the meeting and went to the Unit. On the Unit, she assessed and interviewed Patient #6, it was at this time he/she made a formal abuse allegation involving Program Coordinator (PC) #1. She stated she and the Unit DON escorted PC #1 to Nursing Services, and she (UM 3L) went to review the video with Risk department. Leadership was notified and PC #1 was put on administrative time off (ATO).

During an interview, on 11/08/2023, at 12:36 PM, with the Director of Patient Safety (DPS), he stated that he is made aware of all incidents, the Management team reviewed the previous day's events every morning. Leadership would then assign follow-up based on the criticality and the resource best suited to investigate but all events were tracked until resolved.

While continuing the interview, the DPS stated since his arrival in August 2023, he had been advocating for process changes in being mechanically restraint free, that was the goal and best practice. Additionally, the DPS stated he had formulated a mechanical restraint free environment education for staff; however, the education had not been finalized and presented prior to the State Survey Agency (SSA) Surveyor entering the facility.

He further stated it boiled down to performing the least restrictive physical intervention while allowing the patient the opportunity to use their own coping skills without having someone controlling them. The message is simple; don't put hands on, have someone with you.

Additionally, the DPS stated a goal is to institute the hands free physical/mechanical holds interventions and to change the mindset from "we've always done it this way" to focusing on de-escalation without using mechanical holds at the same time.

While interviewing the Chief Nursing Officer (CNO)/Vice-President Patient Care Services, on 11/09/2023, at 9:35 AM, she stated the purpose of the QPS meetings was a collaboration with Risk and other members of the Leadership team to discuss unusual occurrences, and safety/patient concerns. Responsibilities (action items) would be assigned to the team member to investigate, follow-up, and inform QPS members or the appropriate individual.

Continuing the interview, the CNO stated that crisis prevention interventions (CPI) training and certification was an on-going process based on the individual's hire date. Further, she stated the education was presented on hire and possibly quarterly but would verify with the Educator. During the interview, the CNO stated the Director of Patient Safety (DPS) had developed and was preparing to present a staff education eschewing de-escalation without using mechanical holds at the same time at the weekly Nurse Manager meeting. The CNO stated the meeting occurred after the SSA Surveyor's entry into the building.

Further interviewing the Risk Manager on 11/09/2023, at 10:05 AM, he stated that the whole purpose of QPS was for each department to report on process improvement (PI) initiatives and do a deep dive into their own processes to identify areas for improvement.

During an interview with the Professional Development Registered Nurse (RN), on 11/09/2023, at 10:09 AM, she stated that on hire, staff received two (2) full days of CPI/seclusion, restraint education, then that education is presented quarterly based on their hire date.

Additionally interviewing the Director Patient Safety (DPS), on 11/09/2023, at 12:37 PM, he stated there was no failure in the process for the incident on 10/25/2023. The Program Coordinator #1 was in/near the room as per the Behavior Protocol. The failure was that PC #1 did not use an approved physical management hold per CPI.

In a re-interview with the CNO, on 11/09/2023, at 12:53 PM, she stated there was no failure regarding supervision of Patient #6 on 10/25/2023. The failure was PC #1 not utilizing an approved physical management intervention.

While re-interviewing the Director of Patient Safety and the Risk Manager, on 11/09/2023, at 2:02 PM, both stated that all Unit Nurse Managers randomly performed visual checks to observe for rounding being completed as documented or review video footage of things that come through on the electronic reporting system. Additionally, the Quarterly CPI education re-enforced and maintained a safe atmosphere for the patients.

During an interview with the Unit Manager (UM) for 2 Lourdes (2L), a child/adolescent unit, on 11/09/2023, at 2:36 PM, she stated that right now the focus of random, monthly visual checks was to ensure that every fifteen (15) minute rounds were being completed as documented. The process was to select five (5) random patients and in conjunction with the video monitoring system, make walking rounds to ensure staff rounds were being completed and documented correctly. She continued by stating that she spent a lot of time on the Unit so that she could observe staff/patient/patient interactions in real time. Furthermore, she felt education was a major factor in providing a safe environment for the patients.