HospitalInspections.org

Based on interview, record review, policy review and review of video surveillance, the hospital failed to ensure staff:
- Protected patients from physical abuse when staff used excessive force for one current patient (#20) of one current patient reviewed for allegations of abuse on the Preadolescent/Adolescent Behavioral health Unit (PBHU). (A-0145)
- Protected patients from emotional abuse when they placed patients in seclusion (any involuntary physical or confinement of a patient alone in a room where he/she was physically prevented from leaving) as a form of punishment for one current patient (#20) and two discharged patients (#18 and #19) of three patients reviewed for emotional abuse for patients on the PBHU. (A-0145)
- Used appropriate Crisis Prevention Institute (CPI, a type of training where staff learn safe physical holds to restrict a person's movement) techniques for one current patient (#20) and two discharged patients (#18 and #19) of three patients reviewed for appropriate CPI techniques when staff failed to attempt de-escalation and immediately placed hands on the patients on the PBHU. (A-0145)
- Completed a timely and thorough investigation when management staff were aware of inappropriate CPI techniques and potential abuse by staff to one current patient (#20) and two discharged patients (#18 and #19) on the PBHU. (A-0145)
- Obtained seclusion orders for one discharged patient (#19) of two patients reviewed that were placed in seclusion on the PBHU. (A-0168)
- Were trained in first aid (the first and immediate assistance given to any person suffering from either a minor or serious illness or injury) related to restraints (application of mechanical restraining devices or manual restraints which are used to limit the physical mobility of a patient), for eight staff (GG, HH, II, JJ, BBB, GGG, HHH and III) personnel files of nine staff personnel files reviewed. (A-0206)

These deficient practices resulted in the hospital's non-compliance with specific requirements found under the Condition of Participation: Patient's Rights. The hospital census was 314 and the PBHU census was 14.

Based on interview, record review, policy review and review of video surveillance, the hospital
failed to ensure staff:
- Protected patients from physical abuse when staff used excessive force for one current patient (#20) of one current patient reviewed for allegations of abuse on the Pre-Adolescent/Adolescent Behavioral Health Unit (PBHU);
- Protected patients from emotional abuse when they placed patients in seclusion (any involuntary physical or confinement of a patient alone in a room where he/she was physically prevented from leaving) as a form of punishment for one current patient (#20) and two discharged patients (#18 and #19) of three patients reviewed for emotional abuse for patients on the PBHU;
- Used appropriate Crisis Prevention Institute (CPI, a type of training where staff learn safe physical holds to restrict a person's movement) techniques for one current patient (#20) and two discharged patients (#18 and #19) of three patients reviewed when staff failed to attempt de-escalation and immediately placed hands on the patients on the
PBHU; and
- Completed a timely internal investigation for allegations of abuse for one current patient (#20) of one current patient with allegations of abuse.

These failures placed all patients admitted to the hospital at risk for their physical/emotional health and overall safety. The hospital census was 314 and the PBHU census was 14.

Findings included:

1. Review of the hospital's policy titled, "Patient Abuse/Neglect by a Hospital Employee," dated 12/18/18, showed that all patients in the hospital will be protected from abuse by anyone including, but not limited to: staff, other patients, consultants, volunteers, and staff from other agencies providing services to the individual, family members or guardians, friends or any other individual.

Review of the hospital's undated organizational policy/procedure titled, "Restraints: Management of Violent and Self-Destructive Behaviors," showed that the patient has the right to be free from restraints of any form that are not medically necessary or are used as a means of coercion, discipline, convenience or retaliation by staff.

Review of the hospital's undated instructor CPI manual titled, "Crisis Prevention Institute," showed direction for the training instructor as follows:
- Develop limit-setting strategies when verbally intervening to de-escalate defensive behaviors.
- Learn safety intervention strategies to maximize safety and minimize harm.
- De-escalate the potential crisis situation by using appropriate verbal interventions with a person demonstrating defensive behaviors.
- You are obligated to reduce use and prevent the misuse and abuse of safety interventions.
- Any restrictive intervention should be used as a last resort. It should be reasonable, proportionate, and least restrictive to maximize safety and minimize harm.
- Apply the outside/inside principle by placing something on the outside and something on the inside of the limbs and/or body.

Review of Patient #20's medical record showed that the patient was a 12-year-old transgender female admitted to the hospital on 03/30/21, for suicide (to cause one's own death) attempt with ingestion of bleach with intent to harm. She had a past medical history of multiple psychiatric (relating to mental illness) diagnoses and prior suicide attempts. The discharge summary note showed that the patient had complained of right elbow pain after she reported she had hit it on the wall during an escalation event. X-rays (type of radiation called electromagnetic waves, that creates pictures of the inside of the body) were obtained and no evidence of fracture or other injury were noted.

Review of the hospital-provided video recording titled, "Clip 3," dated 04/05/21, showed:
- 7:52:14 PM Staff II, Mental Health Coach (MHC), walked into camera view with Patient #20 directly in front of him. Staff II appeared to have his hands on the patient's upper body.
- 7:52:16 PM Staff II leaned into the patient's doorway to her room. Staff II's right arm extended out and pushed the patient into her room with excessive force that resulted in the patient stumbling quickly in a forward motion.
- 7:52:21 PM Staff II exited the patient's room and Patient #20 followed him and attempted to exit her room when Staff HH, Registered Nurse (RN), walked toward the patient and placed her right arm around the bend of Patient #20's right arm.
- 7:52:31 PM Patient #20 resisted and was turned around in a circle by Staff HH then Patient #20 dropped herself to the floor; Staff HH had both hands on the patient's right arm and pulled at her sweatshirt while Staff II grabbed at the patient's left arm/shoulder area.
- 7:52:34 PM Staff HH, RN, and Staff II, MHC, dragged the patient into her room then Staff II held onto the patient's lower legs and lifted them off of the floor and Staff HH carried the patient's upper body.
- 7:53:30 Patient #20 appeared into camera view and fell towards her bed with Staff II's arm visibly extended out toward the patient and he appeared to have pushed the patient.

Staff II, MHC, used excessive force when he pushed Patient #20 twice. Once into her room, and once that resulted in her falling into the side of her bed. Staff II and Staff HH, RN, both used inappropriate CPI techniques with Patient #20 when they dragged her then grabbed her by her legs and arms and suspended her over the floor and carried her into her room.

Review of the hospital-provided video recording titled, "Clip 5," dated 04/05/21, showed:
- 7:54:59 PM Patient #20 entered into camera view when she was escorted to the seclusion room doorway with both arms behind her as Staff II, MHC, held her right arm and Staff JJ, MHC, held her left arm.
- 7:55:00 PM Patient #20 entered the seclusion room quickly and abruptly as the patient appeared to have been pushed into the room, which caused her to hit the wall with her arms extended outwards and her hands slapped against the wall.
- 7:55:56 PM Staff closed the door to the seclusion room.
- 7:55:59 PM Patient #20 attempted to rip up a padded mat inside the room.
- 7:56:05 PM Staff GG, RN, Charge Nurse, entered the room and stated "that was enough" and was heard to ask someone to help her get the mat out of the room.
- 7:56:22 PM Staff GG and Staff JJ, MHC, entered the room and Staff GG pushed Patient #20 away from the mat with excessive force that resulted in the patient falling onto the floor.
- 7:56:29 PM Patient #20 immediately got up and grabbed at the mat as Staff GG exited the room.
- 7:56:31 PM Staff JJ grabbed the patient's right arm and twirled her around in a circle and back into the room and stated, "You just broke my nail," then exited the room.

Staff II, MHC, and Staff JJ, MHC, used excessive force when they pushed Patient #20 into the seclusion room, which resulted in her body hitting against the wall. Staff GG, RN, used excessive force when she pushed the patient away from the mat which resulted in the patient's fall to the floor. Patient #20 verbalized right elbow pain to staff following this seclusion; however, no incident report was completed regarding the possible injury.

2. Review of Patient #18's medical record showed that he was a 12-year-old male who was admitted on 03/31/21, with concerns for suicidal/suicidal ideation (SI, thoughts of causing one's own death). The patient had a past history of multiple psychiatric diagnoses.

Review of the hospital-provided video recording titled, "Incident 1, View 1," dated 04/05/21, showed:
- 7:21:42 PM Patient #18 walked away from camera view toward Staff GG, RN, who was standing in the hallway.
- 7:21:42 PM Staff GG immediately raised her arms and placed her hands on the patient's arms and began to walk him backwards down the hallway.
- 7:21:44 PM The patient and Staff GG turned in a circle while they held hands and Staff GG twisted Patient #18's right arm backwards.
- 7:21:49 PM Staff II, MHC, walked up behind Patient #18 and placed his hand under the patient's upper left arm while Staff GG grabbed his right arm and both staff walked behind the patient to his room where the patient walked inside his room; staff closed the door and walked away.

Staff GG, RN, appeared to make no attempt to verbally de-escalate Patient #18 when she immediately placed her hands on the patient and used inappropriate CPI techniques when she twisted his arm backwards.

3. Review of Patient #19's record showed that the patient was an 11-year-old female who was admitted on 04/01/21, for recent aggression toward her foster parent. The patient had a past history of multiple psychiatric diagnoses.

Review of the hospital-provided video recording titled, "Clip 6, Part 1," dated 04/05/21, showed:
- 8:29:02 PM Patient #19 walked backwards down the hallway in front of her room while Staff GG, RN, walked toward her. Staff II, MHC, was seated in a chair nearby.
- 8:29:05 PM Staff GG placed her left hand onto Patient #19's upper right arm and abruptly walked the patient backwards into her room.
- 8:29:11 PM Staff GG turned the patient around in a circle while she held the patient's hand and grabbed at her right arm and appeared to have pushed the patient to the floor.
- 8:29:13 PM Staff GG and the patient appeared to struggle and Staff II, MHC, stood up from the chair, walked toward the room and stopped in the doorway.
- 8:29:15 PM Staff GG walked out and closed the patient's door and stood in front of the door with her hands on the doorknob.
- 8:29:23 PM The door opened while Staff GG appeared to lean in as if the patient had opened the door.
- 8:29:35 PM Staff GG closed the door and again stood in front of the door with both hands on the doorknob in what appeared to be an attempt to keep the door closed. The patient was visible through the partially opened window blinds and stood on the other side of the door.
- 8:29:38 PM Staff GG opened the door and appeared to talk to the patient with Staff II, MHC, in the doorway.
- 8:30:20 PM Patient #19 attempted to exit her room and Staff GG repositioned herself to block the patient from exiting.
- 8:30:23 PM Staff GG placed her right hand onto the patient and walked the patient back inside her room.
- 8:30:30 PM Staff GG again repositioned herself in the patient's doorway to block the patient from her attempts to exit her room.
- 8:31:00 PM Staff II, MHC, entered the patient's room and out of camera view.
- 8:31:37 PM Staff HH, RN, stood in the patient's doorway.
- 8:31:57 PM Staff GG and Staff HH entered the patient's room and exited with each to the patient's side with their hands to the patient's upper arms and escorted the patient down the hallway and out of camera view.

Staff GG, RN, used immediate hands on with Patient #19 and appeared to have pushed her to the floor when the patient resisted. Staff GG closed the door to the patient's room and held it closed. After the door was opened, Staff GG positioned herself to block the patient from exiting her room, keeping the patient secluded in her room.

During an interview on 04/20/21 at 10:00 AM, Staff II, MHC, stated that prior to report on the evening of 04/05/21, Staff GG, RN, Charge Nurse told the staff to keep the patients in their rooms. He stated that the patients would not stay in their rooms after being told they were supposed to. He stated that he remembered that Patient #20 wouldn't stay in her room and he recalled that he and Staff JJ, MHC, had to take her back to her room and that Staff JJ had the patient's arm and he had her leg. Staff II stated that keeping the patients in their rooms wasn't something that they normally did. He stated that he didn't remember that he pushed Patient #20 onto her bed and did not feel any of the staff's actions that night were abusive.

During an interview on 04/20/21 at 10:45 AM, Staff JJ, MHC, stated that prior to report on 04/05/21, the day shift informed the night staff that the patients had room time during the day and Staff GG, RN, told the night staff that the patients were to remain in their rooms and if they didn't behave they wouldn't get their evening snack. She stated that Staff GG had instructed her to take Patient #19 into seclusion but she wasn't sure why. Staff JJ stated that when Patient #20 was in the seclusion room and attempted to rip up the padded mat/pillow, Staff GG pulled it away from her and the patient fell backwards. Staff JJ stated that Patient #20 informed her that her elbow was "broken" and that she informed both Staff GG and Staff HH, RN, and asked if she could give the patient an ice pack. Staff JJ stated that the nurses didn't say anything about the patient's arm or possible injury.

During an interview on 04/20/21 at 11:45 AM, Staff HH, RN, stated that per report, the day shift had told the patients they were to stay in their rooms, and after huddle report, they (night shift) told them to stay in their rooms. She stated that it wasn't discussed as a team but that Staff GG, RN, stated that it would be for the best but this wasn't standard practice making the patients stay in their rooms.

During an interview on 04/20/21 at 12:30 PM, Staff GG, RN, stated that she was the charge nurse on the night shift for 04/05/21, and that the day shift staff had reported that the patients were non-compliant and argued with staff so the team decided that until medications had been given, the patients were to stay in their rooms. She stated that the patients refused to take their medications, didn't want to stay in their rooms and were verbally aggressive. Staff GG stated that Patient #18 was very impulsive with poor boundaries and that he raised his hands to her and she thought he was coming towards her and she had planned to block him but she just reacted with grabbing his arms and she knew she shouldn't have reacted that way. She stated that Patient #19 told the other patients not to listen to the staff and that she wasn't a part of her seclusion, but once she was in seclusion, the other patients settled down. She stated that Patient #20 fed off of others' behaviors and that she and the other patients didn't want to stay in their rooms so she flooded her bathroom. Staff GG stated that after this occurred, the patient was placed in a therapeutic hold then taken to the seclusion room. She stated that when she removed the padded mat from Patient #20 in the seclusion room, the patient was holding on to it so when it was removed, she fell forward.

During an interview on 04/20/21 at 1:00 PM, Staff OO, RN Educator, stated that he trained staff on CPI and that verbal de-escalation was the focus. He stated that he watched the video recordings and felt that the staff knew better than to put hands on and use techniques that were not taught in the training and that it wasn't the hospital's standards of practice.

Review of Staff GG's, RN, personnel file showed that she had completed training for Abuse Awareness and Child Abuse and Neglect on 04/20/20; Restraints for Clinical Staff on 06/19/19; Safe Training and Responsible Restraints (STARR) on 07/02/19; and Crisis Prevention through Verbal and Non-Verbal De-escalation Strategies on 07/01/19.

Review of Staff HH's, RN, personnel file showed that she had completed training for Abuse Awareness on 04/18/20 and Child Abuse and Neglect on 04/23/20.

Review of Staff II's, MHC, personnel file showed that he had completed training for Crisis Prevention through Verbal and Non-Verbal De-escalation Strategies on 09/15/20 and Preventing Workplace Violence (CPI) on 09/07/20.

Review of Staff JJ's, MHC, personnel file showed that she had completed training for Abuse Awareness on 04/15/20 and Child Abuse and Neglect on 04/16/20.

During an interview on 04/19/21 at 2:10 PM, Staff L, PBHU Manager, stated that when the night shift reported for work on 04/05/21, they instructed the patients to stay in their rooms and the patients were not happy and yelled about it. He stated that the day shift had told the night shift staff that the patients had been disrespectful during the day and that night shift decided before they had any interactions with the patients to make them stay in their rooms and this was not the usual process. Staff L stated that he learned later that the patients were told to stay in their rooms or they would be put into the seclusion room. He stated that this was not his expectation of how to communicate with the patients. He stated after he viewed the videos, he was concerned with the hands on and the placement of the staffs' hands on the patients' arms and that he had struggled with Staff GG, RN, in the past and had prior conversations with her regarding her performance.

During the night shift of 04/05/21, PBHU staff used excessive force with Patient #20 and used inappropriate CPI techniques with Patients #18, #19 and #20, and told all inpatients on the PBHU that they had to stay in their rooms and if they didn't they would be placed in the seclusion room after it was reported that the patients had been disrespectful during the day by the day shift staff. These actions were both physically and emotionally abusive as the seclusion of patients to their rooms was used as a form of punishment.

4. Review of the hospital's policy titled, "Patient Abuse/Neglect by a Hospital Employee," dated 12/18/18, showed that:
- Upon notification of suspected abuse/neglect at the hospital, an internal investigation will begin immediately.
- If abuse was witnessed or alleged to have occurred while the patient was at the hospital, either as an inpatient or outpatient setting, the members of the care team should notify the unit/department manager and/or the administrative supervisor of the suspected abuse, who would notify Risk Management.
- Interviews should be conducted with involved team member(s) as soon as possible.

During an interview on 04/19/21 at 2:10 PM, Staff L, PBHU Manager, stated that he received a phone call on the evening of 04/05/21, from Staff FF, Nurse Practitioner (NP), PBHU. Staff L stated that Staff FF was concerned that Staff GG, RN Charge Nurse, PBHU, had called her and requested to not admit any further patients for that shift. Staff L called Staff GG and asked why she had made the request but he did not get any details until the next morning. Staff L stated that he was able to view video feed from his home and that he did so on the evening of 04/05/21, but he only viewed inappropriate CPI techniques between Staff GG and Patient #18. He did not review any further video at that time. Staff L stated that there were no event reports to review the morning of 04/06/21, but he was aware that some patients had been placed in seclusion the evening prior. He stated that additional video review wasn't conducted until 04/07/21, and that staff interviews were not conducted until 04/08/21.

Review of email correspondence dated 04/06/21 at 2:50 PM, from Staff L, PBHU Manager, to Staff GG, RN Charge Nurse; Staff HH, RN, PBHU; Staff II, MHC, PBHU; and Staff JJ, MHC, PBHU, showed that Staff L understood that three patients had been placed in seclusion the night before and that he wanted to debrief the events with them and asked for them to correspond with a couple of times that would work for them. The email also stated that there were no event reports of the seclusion events and that "ideally" those needed to be completed before clocking out for the shift.

Review of email correspondence dated 04/06/21 at 3:28 PM, from Staff KK, Social Worker, to Staff L, PBHU Manager, showed that Staff KK had been informed that Patient #20 had reported to her that she had flooded her bathroom the night of 04/05/21, and that she was "snatched" out of the room and "dragged" to the seclusion room by staff. Patient #20 denied physical aggression toward staff prior to when this occurred. Staff KK was concerned that what the patient had reported was different than the documentation by staff in the medical record.

Review of the hospital's internal investigation titled, "Risk Management and Regulatory Department Event Summary," dated 04/09/21, showed that Staff L, PBHU Manager, was notified by Social Work of a patient complaint of abuse on the evening of 04/06/21, and that he performed a preliminary investigation and reviewed video on 04/07/21, and notified the Risk Management Manager and Human Resources. Interviews with involved staff members were not conducted until 04/08/21, and house-wide education was not initiated until 04/09/21.

Staff L, PBHU Manager, was aware of the inappropriate CPI techniques used by his staff to the patients on the evening of 04/05/21, and he was made aware of the alleged abuse by staff to a patient on 04/06/21, and a full investigation was not initiated until 04/07/21.






39563

Based on interview, record review, policy review, and review of video surveillance, the hospital failed to ensure that hospital staff followed their policy for seclusion (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving) and recognized that their actions met the definition of seclusion for one discharged patient (#19) of two patients reviewed who were placed in seclusion on the Adolescent/Preadolescent Behavior Health Unit (PBHU). These failures placed all patients placed in restraint/seclusion at risk for their health and safety. The hospital census was 314 and the PBHU census was 14.

Findings included:

1. Review of the hospital's policy titled, "Restraints," dated 12/2018, showed the following:
- The hospital is committed to providing a physical, social, and cultural environment which promotes the initiation of the least restrictive measures to support the comfort, security, and safety of the individual and others.
- The use of restraints (any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely) and seclusion is limited to clinically appropriate and adequately justified situations after all appropriate alternatives have been utilized.
-Restraint orders may be written, verbal or telephone; however, a face to face physician or other licensed independent practitioner (LIP) evaluation must be done within one hour of initiation of restraint.
- In an emergency situation, a registered nurse (RN) may initiate restraint with the physician or other LIP completing the face to face evaluation and writing of restraint orders within one hour.

Review of Patient #19's medical record showed that the patient was an 11-year-old female who was admitted on 04/01/21, for recent aggression toward her foster parent. The patient had a past history of multiple psychiatric (relating to mental illness) diagnoses.

Review of the hospital-provided video recording titled, "Clip 2," dated 04/05/21, showed:
- 7:46:53 PM Patient #19 stood against the wall in the patient unit hallway while Staff II, Mental Health Coach (MHC), stood in front of her, and they appeared to be talking.
- 7:47:01 PM Staff II reached down and placed his left hand on Patient #19's right upper arm and grasped the patient's underneath of her right arm and escorted her down the hallway.
- 7:47:07 PM Staff HH, RN, entered the hallway from a patient's room and followed Patient #19 and Staff II down the hallway and out of camera view.

Review of the hospital-provided video recording titled, "Clip 7," dated 04/05/21, showed:
- 7:47:16 PM The seclusion room door was open with the light off.
- 7:47:20 PM Staff II, MHC, and Staff JJ, MHC, entered into the seclusion room with Patient #19, both staff exited the room, closed the door and turned the light on inside the room.
- 7:47:25 PM Patient #19 lowered herself to the floor in a corner and put her head down onto her arms.
- 7:49:34 PM The seclusion room door opened and Staff JJ entered, sat on the floor, and began to talk with the patient.

Review of Patient #19's medical record showed no order for the seclusion that initiated at approximately 7:47 PM on 04/05/21.

Review of the hospital's internal investigation titled, "Event Summary," dated 04/13/21, showed that at 7:47 PM, Patient #19 was escorted by Staff II, MHC, to the seclusion room, the door was closed (not locked) and that no order was obtained for this seclusion.

2. Review of the hospital-provided video recording titled, "Clip 6, Part 1," dated 04/05/21, showed:
- 8:29:02 PM Patient #19 walked backwards down the hallway in front of her room while Staff GG, RN, walked toward her. Staff II, MHC, was seated in a chair nearby.
- 8:29:05 PM Staff GG placed her left hand onto Patient #19's upper right arm and abruptly walked the patient backwards into her room.
- 8:29:11 PM Staff GG turned the patient around in a circle while she held the patient's left hand with her left hand and with her right hand on the patient's upper right arm and attempted to place the patient onto the floor.
- 8:29:13 Staff GG and the patient appeared to struggle and Staff II, MHC, stood up from the chair, walked toward the room and stopped in the doorway.
- 8:29:15 PM Staff GG walked out and closed the patient's door and stood in front of the door with her hands on the doorknob.
- 8:29:23 PM The door opened while Staff GG appeared to lean in as if the patient had opened the door.
- 8:29:35 PM Staff GG closed the door and again stood in front of the door with both hands on the doorknob in what appeared to be an attempt to keep the door closed. The patient was visible through the partially opened window blinds and stood on the other side of the door.
- 8:29:38 PM Staff GG opened the door and appeared to talk to the patient with Staff II, MHC, in the doorway.
- 8:30:20 PM, Patient #19 attempted to exit her room when Staff GG repositioned herself to block the patient from exiting.
- 8:30:23 PM Staff GG placed her right hand onto the patient and walked the patient back inside her room.
- 8:30:30 PM Staff GG again repositioned herself in the patient's doorway to block the patient from her attempts to exit her room.
- 8:31:00 PM Staff II, MHC, entered the patient's room and out of camera view.
- 8:31:37 PM Staff HH, RN, stood in the patient's doorway.
- 8:31:57 PM Staff GG and Staff HH entered the patient's room and exited with each to the patient's side with hands to the patient's upper arms and escorted the patient down the hallway and out of camera view.

Patient #19 was physically placed inside of her room and the door was held closed by Staff GG, RN, who prevented the patient from leaving her room. This met the definition of seclusion, according to the hospital's policy. Review of Patient #19's medical record showed no order for this seclusion event.

During an interview on 04/20/21 at 12:30 PM, Staff GG, RN, stated that she agreed that if a patient was physically held in their room it was considered seclusion, and that if the seclusion door wasn't locked it did not require an order.

During an interview on 04/19/21 at 2:20 PM, Staff L, PBHU Manager, stated that on the night shift of 04/05/21, it was reported to him that the patients had been told to stay in their rooms or be placed into seclusion. He stated that this wasn't his expectation for patient treatment and that Patient #19 had been placed into seclusion at 7:47 PM on 04/05/21, with no order.




39563

Based on interview, record review and policy review, the hospital failed to ensure that staff were trained in first aid (the first and immediate assistance given to any person suffering from either a minor or serious illness or injury) related to restraints (application of mechanical restraining devices or manual restraints which are used to limit the physical mobility of a patient), for eight staff (GG, HH, II, JJ, BBB, GGG, HHH and III) personnel files of nine staff personnel files reviewed. This failure had the potential to result in serious injury or death to patients who required restraints in the hospital. The hospital census was 314.

Findings included:

Review of the hospital's policy titled, "Restraints," dated 12/2018, showed the following:
- A physical restraint was any manual method, physical or mechanical device (polyurethane/leather limb holders, soft limb holders, elbow immobilizers), material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely.
- Safe and effective use of restraint devices were demonstrated initially and validated at least annually for staff members who applied, removed, monitored, assessed and provided care to patients in restraints as per reference attachment B titled, "Educational Requirements for Staff Caring for Patients in Restraints."
- Implementation of restraints included the observation for any evidence of circulatory restriction (loss of sensation, decreased pulses, change in color/temperature, swelling), skin breakdown, respiratory restriction (a restriction in the amount of air flowing in and out of the airways), alterations in level of consciousness (the state of being fully alert, aware, oriented, and responsive to the environment), increased agitation and/or restlessness.

Review of the hospital's undated policy attachment titled, "Appendix B, Educational Requirements for Staff Caring for patients in Restraint/Seclusion," showed that all Registered Nurses (RNs), Patient Care Technicians (PCTs), Patient Safety Assistants (PSAs), Mental Health Coaches (MHCs), Emergency Medical Technicians (EMTs), and Emergency Medical Technician - Paramedics (EMT-Ps) who apply/remove, monitor, assess and provide care to patients in restraints will be trained on safe and effective use of restraint devices.

Review of the educational slide given to RNs, PCTs, PSAs, MHCs and EMTs showed that all signs of physical distress such as breathing difficulties, changes in circulation, neurovascular (related to or involving the nerves and blood vessels) or psychosocial (relating to the interrelation of social factors and individual thought and behavior) status should be reported to the medical team immediately and that the PCT/PSA/EMT was to initiate appropriate first aid until the RN arrived.

The education given to the staff who applied, removed, monitored or assessed patients in restraints did not include training for first aid in relation to restraints.

Review of the hospital's restraint log showed a total of 161 patients required violent and/or non-violent restraints for the previous six months.

Review of eight personnel records for Staff GG, RN; Staff HH, RN; Staff II, MHC; Staff JJ, MHC; Staff BBB, RN; Staff GGG, RN; Staff HHH, PCT and Staff III, PCT, showed no restraint first aid training.

During an interview on 04/20/21 at 12:45 PM, Staff W, RN, stated that he did not receive specific first aid training and that it would be a "case to case" scenario.

During an interview on 04/21/21 at 1:20 PM, Staff FFF, Clinical Education Manager, stated that the restraint training provided to staff did not include first aid training specific to restraints and that staff did not receive a general first aid class.