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Based on staff interviews, review of video surveillance and record reviews, the facility failed to protect and promote the rights of patient #1 because staff did not follow facility policy and procedure on the use of restraints and seclusion during the 02/19/12 restraint of patient #1.

Although the facility terminated RN #1 due to her inappropriate restraint and failiure to appropriately document the restraint of patient #1, as of 02/28/12, patient #1 remained in the facility and all staff who participated in the restraint have not been retrained on following facility policy and procedures on the use of restraints and seclusion. Patient #1 continued to display verbal and physical aggression that could require restraint and/or seclusion after the 02/19/12 restraint.

Cross Reference CFR 482.13 (e).

Based on staff interviews, review of video surveillance, and record reviews, the facility failed to follow their own policy and procedure on Restraint and Seclusion of Patients. The facility failed to obtain a physician's order after the use of behavioral restraints on 02/19/12 for one of one restrained patients (patient #1). After terminating the employment of one registered nurse (RN#1) due to not following the facility policy and procedure on the use of restraints, the facility failed to retrain all staff who were involved in the application of the restraint to patient #1. Patient #1 remained in the facility as of 02/28/12 and continued to display verbal and physical aggression that had required a restraint on 02/27/12.

Findings included:

Interview in the administrative conference room on 02/28/12 at 10:30 AM with Director of Clinical Services revealed that she and other administrative staff were familiar with the complaint regarding the 02/19/12 restraint of patient #1 and the facility was still in the process of completing their investigation. She stated the facility terminated the employment of RN #1 on 02/27/12. She stated they have not completed other personnel actions or retrained all staff on the use of restraints. She confirmed that other staff involved in the restraint of patient #1 continue to work at the facility.

Interview in the nursing supervisor's office on 02/28/12 at 10:45 AM with the Program Manager for the Adult/Geriatric Unit revealed that patient #1 asked to speak with her on Monday 02/21/12. She stated patient #1 reported a nurse (RN #1) "restrained her and in the process choked her and threatened to medicate her if she did not start behaving." The Program Manager questioned staff that was on duty at the time of the restraint and was able to get written statements from all staff involved; she had submitted them to Risk Management to help with the facility investigation. She's stated that RN #1's employment had been terminated. The Program Manager stated that she had been conducting re-training of staff on proper documentation and the application of restraints but has not documented the training. She confirmed that all staff who may provide care for patient #1 have not been re-trained on the use of restraints.

Interview in the nursing supervisor's office of Mental Health Technician (MHT) # 1 on 02/28/12 at 11:00 revealed that on 02/19/12 in the morning time, he was trying to get one of the patients to get out of the quiet room because the facility does not allow female and male patients to be in the same room together. The female and male patient were not receptive to one of them leaving the quiet room, and the female was very vocal about it. She requested to go talk to registered nurse (RN) #2 and walked out of the room only to return and try to force herself back into the quiet room. Mental Health Technician #1 stated he was blocking the door as to not to allow her back in the room, but patient forced herself into the room and tried to hit him. During the scuffle a registered nurse #1 walked into the room and grabbed the female patient and somehow fell to the ground. Mental Health Technician #1 stated he assisted the male patient out of the room. RN #1 and another female staff member restrained the Patient #1 on the ground. He stated he walked out of the room to help guide other patients out of the area. He stated that he is usually able to talk to the Patient #1 and de-escalate the situation by talking to her and that is what he was trying to do, but RN #1 walked in and took immediate action without trying to speak to the patient. He stated that he has only had to physically restrain a patient once or twice during the four years he has worked here and that was only to protect the patient from causing harm to themselves or staff. He stated that the RN #1 did not try to speak to the patient to de-escalate her aggressive behavior before initiating the restraint. He stated he did not know who to report the incident to since RN #1 was the charge nurse for the unit. He stated that after the 02/19/12 restraint, supervising staff reminded staff of the proper use of restraints and proper documentation.

Interview in the nursing supervisor's office on 02/28/12 at 11:15 AM with MHT #2 revealed the following: MHT #2 was in the day room where the patient had been wrestled to the floor and she assisted with the restraint of patient #1 by holding down her feet. She stated RN #1 was speaking to the patient in a rough manner during the time patient #1 was restrained on the floor. MHT #2 described RN #1 as unprofessional and she had never seen a nurse behave like RN #1. When asked about prior use of restraints at the facility, MHT #2 stated that she had not restrained a patient in the three years that she had worked at the facility. MHT #2 stated that she verbally de-escalates and calm patients down, and the facility trains all staff to use verbal de-escalation when dealing with aggressive patients. MHT #2 was asked why she did not report this incident to anyone until asked about it by the Program Manager, she was unable to give a reason. She confirmed that she has not been retrained on appropriate restraining of patients since the 02/19/12 restraint of patient #1.

Interview in nursing supervisor's office on 02/28/12 at 2:20 PM with RN #2 revealed that when he entered the quiet room, he saw RN #1 on the floor restraining patient #1. RN #1 instructed him to get an as needed (PRN) medication for patient #1 and he complied. He stated that during the time of the restraint, he overheard RN #1 tell patient #1 that "I am going to give you a shot. Are you going to give me a hard time?" He indicated that he assumed RN #1 who was the charge nurse would document the restraint.

Review in the Adult/Geriatric Manager's Office on 02/28/12 of video surveillance for 02/19/12 restraint of patient #1 revealed the following: In the quiet room otherwise known as the " fish bowl ", two patients, one male and one female (Patient #1) were sitting on opposite ends of a couch. MHT #1 entered the room and started speaking to the patients. This went on for a couple of minutes and then the Patient #1 walked out of the room. Patient #1 returns and tried to get back into the room, but MHT #1 was blocking the door. There was a struggle and eventually Patient #1 got into the room, the struggle continued towards the back corner of room, and the struggle was almost out of sight. A female staff member (identified as RN #1) rushed in the room and grabbed patient #1. Patient #1 and RN #1 struggled and ended up on the floor with the RN #1 laying on top of patient #1. MHT #2 arrived and held the legs and feet of patient #1. A male staff (identified as RN #2) walked into the room and walked out. RN #2 returned with an injectable medication and administered the medication to patient #1. Staff members relaxed the hold on the patient and eventually the patient was released.

Continued review of the video surveillance from 02/19/12 revealed a second scene whereby patient #1 was escorted into a quiet room by MHT #1 and then RN #1 entered the room in a very threatening manner, stood in front of patient #1 with her arms crossed and legs slightly spread apart. Patient #1 started to become agitated and MHT #1 stood between RN #1 and patient # 1. RN #1 was seen pointing at patient #1 and appeared to be talking to her. This continued for several minutes and patient #1 seemed to be getting more and more agitated. RN #1 walked out of room and MHT #1 was seen talking to patient #1 who sat on a mat in the room. MHT #1 sat next to patient #1 and they appeared to be talking.

Record review on 02/28/12 of patient #1's medical record revealed she was admitted to the facility on 02/10/12 and remains in-patient at the facility. The patient's admitting diagnoses included bipolar disorder, depressed with psychotic features, hypertension, borderline diabetes, hypothyroidism, moderated to severe psychosocial stressors, inability to stay in a group home, and family disillusion.

Record review of patient #1's medical record on 2/28/2012 revealed the medical record did not contain a physician's order for the 02/19/12 restraint, any licensed independent practitioner or medical doctor evaluation after the use of a restraint. Review of patient #1's nursing notes for 02/19/12 did not reveal documentation for the use of the restraint of patient #1 or documentation regarding the events leading to the use of the restraint. Patient #1's nursing notes for 02/27/12 revealed that on 02/27/12 and documented on 02/27/12 at 1531, "patient #1 became combative to her assigned one to one staff (MHT #1) punching and tearing around door area. Patient was not listening to verbal redirection and eventually needed to be physically restrained as explained by staff. During the restraint, patient #1 bit MHT #1 to his left bicep. RN #2 gave patient #1 a PRN injection during the time of this restraint."

Record review on 02/28/12 of Restraints and Seclusion, Policy#RBC-LD-1015, effective 09/06, last revised 04/11 revealed the following: The facility " is committed to preventing, reducing, and striving to eliminate the use of restraints. The hospital attempts to prevent emergency situations that have the potential to lead to the use of restraints and employs the use of nonphysical interventions when possible as the preferred alternative to restraint use.
Summary: (1) Restraint is 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. General provisions for restraint and seclusion: Indications: (a) Restraint or seclusion may only be used when less restrictive means are not sufficient to protect the physical safety of patients, staff members or others. Initiation: each episode of restraint or seclusion shall be initiated(a) upon the order of a licensed independent practitioner who is responsible for the patient, or (b) by a trained registered nurse when she determines it is necessary to protect the patient. An order from a licensed independent practitioner who is responsible for the patient shall be obtained immediately after such situation (in this instance " immediate " means as soon as it is clinically appropriate to pause in the process of providing care)"

Record review on 02/28/12 of Registered Nurse (RN) #1's Employee Discipline Form, dated 02/27/12, revealed that RN #1 was terminated due to not documenting the 02/19/12 restraint of patient #1 and "not following the Crisis Prevention Intervention (CPI) technique used by the facility to de-escalate agitated patients. CPI requires the use of therapeutic communication, identifying early signs of physical restraint as a last resort only when other interventions have been unsuccessful. It does not teach staff members to restrain patients on the floor. Staff members are taught to release a patient immediately in the event that a physical restraint ends on the floor. RN #1 violated facility policy and procedures. She used a technique which is not taught in CPI. She violated patient's rights by threatening and intimidating a patient. She provoked a patient in the quiet room with her gesture, stance, and presence. She failed to follow LD policy 1015 "Seclusion and Restraints" by not documenting the restraint episode, and not notifying the Program Manager of the use of the restraint. She failed to get a restraint order from the physician. She failed to conduct a debriefing after the restraint incident. She failed to assess the patient and staff members for injury. She failed to provide and maintain a therapeutic and safe environment for the patients and the staff members."