HospitalInspections.org

This CONDITION is not met as evidenced by:

Based on observation, interview, and document review, the hospital failed to ensure the physical safety of patients with behavioral symptoms, for 3 of 5 patients reviewed, (P1), (P3), and (P4), who were either restrained by an unapproved procedure or inflicted self-harm by obtaining contraband substances in the treatment environment. This resulted in an Immediate Jeopardy (IJ) situation for all 5 patients at the facility and any future patients who might seek treatment at the hospital for behavioral symptoms.
The findings include:

The hospital did not meet the Condition of Participation of Patient Rights at 42 CFR 482.13. These deficient practices had the potential to impact all patients with behavior symptoms.

The IJ was called on 5/11/15 at 5:30 p.m. The IJ began on 5/3/15 when the facility failed to ensure the adequacy of a system to prevent patient abuse when a patient was restrained by staff in a punitive, unsafe manner that resulted in multiple injuries to the face. The hospital's failure to protect residents resulted in a second patient unreasonably and dragged across a floor. The hospital failed to ensure that patients were free from unnecessary restraints when they were restrained by staff in an unapproved, unsafe manner.
The hospitals established protocols for contraband, maltreatment, and restraint use had not been implemented by staff to provide a safe patient enviroment for the therapeutic treatment of behavioral symptoms of P1, P3, and P4. Despite P1's "sanitized" enviroment P1 still obtained contraband, ingested inedible items or inserted items, and developed septic shock that required hospitalization at another hospital for approximately 20 days. This patient did not return to the hospital. P3 was restrained when staff placed P3 in an prone position by twisting her arm behind her back and putting her on the ground face first. P3 sustained facial injuries. P4 was restrained when staff held both arms behind his back while sitting on the floor and dragged him approximately 6 to 8 feet. P4's restraint did have the potential to result in bodily harm. Both restraint procedures are unauthorized, unsafe, and punitive. The unauthorized restraints for P3 and P4 required incident management of maltreatment to protect the health and safety of the patients. The hospital was to take corrective action when there was a report of alleged or suspected maltreatment and to thoroughly investigate the incident.
The failure to ensure staff followed the hospital's approved systems for physical intervention and/or environmental modifications to manage patient symptoms such as aggression, noncompliance, pica, and manage incidents of alleged or suspect maltreatment resulted in the hospital's inability to protect the physical safety of patients. Therefore, the hospital was unable to meet the Condition of Participation of Patient Rights at 42 CFR 482.13

The IJ was removed on May 15, 2015 at 11:30 a.m. when an acceptable removal plan was implemented to protect the health and safety of patients. Interviews and document review verified and established that the hospitals leadership had begun a reeducation process for Effective and Safe Engagement Skills (EASE) an 8 hour training to be completed by May 22, 2015 by all staff, immediately reeducated the Charge Registered Nurses on seclusion/restraints and incident management. The Director, Registered Nurse Supervisor, and a Registered Nurse Senior provided supervision on the units from 6:00 a.m. to 9:00 p.m., seven days a week through May 31, 2014 to ensure staff were properly utilizing established protocols, and began the internal investigation process of the incidents of P3 and P4.

Based on observation, interview, and document review, the hospital failed to protect the physical safety of patients for 1 of 5 patients (P1) reviewed, who developed septic shock after obtaining contraband items on 19 occasions that P1 either ingested or inserted into her body. (A144)

Based on observation, interview, and document review, the hospital failed to ensure patients were free from abuse for 2 of 2 (P3) and (P4) reviewed, when staff used non-therapeutic and unauthorized physical restraints. P3 sustained bodily harm with multiple injuries to the face during the restraint procedure. (A145)

Based on observation, interview, and document review, the hospital failed to ensure that patients were free from unnecessary restraints for 2 of 2 patients reviewed (P3 and P4), who were restrained by staff in an unapproved, unsafe manner. P3 sustained multiple injuries to the face during the restraint procedure. (A154)

Based on observation, interview, and document review, the hospital failed to protect the physical safety of patients for 1 of 5 patients (P1) reviewed, who developed septic shock after obtaining contraband items on 19 occasions that P1 either ingested or inserted into her body.

The findings include:

P1's medical record was reviewed. The Vulnerability Assessment and Risk Reduction Plan, dated the day of P1's admission on 11/03/14, indicated that P1 had a potential for self-harm due to her history of self-injurious behavior. Staff were to provide a therapeutic milieu with appropriate levels of observation and privileges. Staff were to introduce, reinforce, and encourage environmental structure.

P1's hospital record indicated that P1 was admitted to the One-Up unit on 11/03/14 at 3:50 p.m. Within three hours of admission, an incident report dated 11/03/14, indicated that P1 found, broke, and ingested parts of a pencil at 6:45 p.m. P1 was taken to a hospital emergency room where an x-ray of the upper gastrointestinal tract found an ink pen and two batteries, but did not reveal pencil parts.

P1's psychiatric assessment, dated 11/05/14, indicated that P1 had been a victim of physical, sexual and emotional abuse from family and family associations, and neglect from her parents. P1 was admitted for acute psychiatric care following discharge from an acute care hospital where P1 had undergone endoscopic procedures to remove foreign bodies from her intestines. P1 had a lengthy history of failed community placements in a variety of settings, due to P1's long history of ingestion of inedible objects, necessitating frequent hospitalizations for foreign body removal. P1's primary diagnosis was Pica. P1's inpatient psychiatric treatment plan was focused on sterilizing the environment to prevent further ingestion of objects. P1 was placed on distant 1:1 monitoring to manage P1's destructive impulses of ingesting inedible objects. All treatment programs was on P1's unit. All personnel who came to P1's unit would remove any pens, objects, pins, earrings, or other small objects that could represent potential items of ingestion.

P1's safety plan, dated 11/10/14, indicated: "The cabinet/closet in the Activity room was emptied and now only contains items that (P1) can have supervised access to. This closet/cabinet must remained locked unless a specific item is requested. This transition is to reduce how often staff must open doors to restricted areas on the unit...staff must avoid opening restricted doors especially when alone in any area with (P1). This is a current list of items permitted in this closet/cabinet: standard deck of cards (2 currently in closet), Uno, Skip Bo, and Phase 10 card games, paper, color crayons and 1 piece of chalk, sensory brush, sensory snacks and candy, a small stack of white foam cups (not permitted to have plastic cups), 3 towels and 1 wash cloth for bathing, 2 quilted blankets, thermometer, blood pressure cuff, stethoscope, 4 band-aids, pumice stone (when it comes) and eucerine lotion." An addendum, dated 11/14/14, indicated: "(P1) is now allowed to wear her own clothes." The One-Up safety plan designed for P1, (updated 02/11/15, original version not retained by hospital) indicated: "All staff will enter the One Up unit via the sensory room only. Programming will be done in assigned rooms only, Staff will not honor her request for items that is off limit rooms. Potentially controversial/dangerous items have been removed from One-Up, staff will not introduce any new items onto the unit. (P1) is not allowed into the metal cabinet in the Activity Room. (P1) is not allowed to have a table or chairs in the rooms she has access to related to her climbing on top and accessing the dropped ceiling." The Weekend Approaches with P1 (undated) indicated: "(P1) is allowed crayons only. No new items are to be introduced. (P1) will remain on a distant 1:1 staffing at all times through the weekend."

Observations of the One-Up unit on 04/30/15 at 8:55 a.m. and 05/05/15 at 7:30 a.m. established that the unit was closed and void of any inpatients. RN Supervisor (RNS)/B accompanied investigators during observations of the unit. RNS/B indicated during the tour where P1's inpatient stay was on the One-Up unit and staff entered One-Up through the unit's sensory room instead of the main door to the unit. RNS/B explained during the tour that when P1 was a patient at the hospital, prior to unit entry, staff emptied their persons of all potentially hazardous items for P1 into a bucket which was located exterior to the sensory room. All doors on One-Up were locked and accessible only by a standard metal key. The only rooms that were unlocked during P1's inpatient stay were P1's bedroom and the tub room, which also had a toilet. P1's bedroom was at the end of the hallway, farthest from the nursing station. P1's bedroom had no bathroom or closet. P1's bedroom contained only a bed and a heavy sand-filled chair. P1 was not permitted to keep any personal belongings in her room. The shower curtain had been removed in the tub room P1 used but the plastic shower curtain hooks were not removed and were still present in the overhead track to the shower. The nurse's station was centrally located on the hallway of inpatient bedrooms. The counter in front of the nurse's locked office had been removed because P1 had climbed onto the top of the counter and removed pieces of the ceiling light. All medications, sharps, treatment supplies, phone, and items necessary for documentation were kept locked in the nurse's office during P1's admission. The mechanical restraint room stored two plastic body shields. P1 frequently utilized the Activity room during waking hours, which contained a cloud-chair (similar to a bean bag chair), a blackboard that was bolted on the wall with P1's daily schedule written in chalk, and a locked metal cabinet containing crayons, paper, chalk, playing cards, card games, and three towels/one washcloth for bathing. P1 also used the Sensory room which contained a cloud chair, a cocoon swing, soft floor mats, and locked closets.

Hospital staffing schedules indicated that multiple nursing staff worked on One-Up during P1's inpatient psychiatric stay between 11/03/14 - 02/17/15.

Documentation of the One-Up units safety plan for P1 included a posted sign outside the entrance to One Up's sensory room (undated) that indicated in bold red letters: "Remove your belongings and place in bucket (Badge, Pens!!, pencils, cell phones, pop cans, plastic med cups, etc.). Leave the bucket on this table as a visual reminder."

Incident reports indicated that during P1's first week as an inpatient on One-Up, P1 ingested contraband items in the environment on 11/3/14, the day of admission, necessitating three separate procedures to remove foreign items from P1's gastrointestinal tract. On 11/03/14 at 6:45 p.m., P1 told staff she ingested a colored pencil. P1 was transferred to hospital #2's emergency room. X-rays were taken where a pen was found and two batteries in P1's stomach, but did not reveal pencil parts. P1 was sent back to the hospital to be monitored and wait for the items to pass through her gastrointestinal tract. The hospital did not have a record of a the 11/3/14 emergency room visit to hospital #2. On 11/5/14 at 10:50 p.m. P1 told staff she swallowed a phone battery. P1 was transferred to hospital #2's emergency room. Hospital #2 medical record dated 11/6/14 at 1:51 a.m. indicated the hospital performed an endoscopic procedure and removed a pen cartridge from the esophagus, and pen, a pencil and 2 batteries from the stomach. On 11/07/14 at 11:00 p.m., P1 ingested an ink pen cartridge and a spring from a pen. P1 was transferred to hospital #2 where they performed and endoscopic procedure and removed a pen cartridge from the esophagus. The hospital did have an emergency room record of the 11/7/14 event. On 11/09/14 at 7:20 p.m., P1 ingested a pencil and was transferred to hospital #2 where they performed an endoscopic procedure and removed ink cartridge from P1's upper esophagus and a colored pencil in P1's stomach. The hospital did have an emergency room record of the 11/7/14 event.

P1's incidents from November 3, 2014 to February 17, 2015 indicated they were part of a pattern. Staff had attempted verbal interventions, had witnessed P1 ingesting items and causing self-harm, or was told by P1 after an ingestion or self-harm behavior occurred. Actions taken to minimize future occurrences included removal of all potential objects that could be swallowed from the unit, staff protocols to follow before entering the unit, hospitalization to remove foreign objects occurred six times, continued therapy with the behavioral analyst and licensed practitioners, distant 1:1 staffing observations, frequent observations, and removal of the open nursing station.

There was no evidence that hospital staff searched the environment for contraband on One-Up, following any of the incidents when P1 obtained contraband substances in the environment on One-Up. There was no evidence that hospital staff made any effort to determine where and when P1 was obtaining contraband items that were known to be dangerous to P1 and potential objects of ingestion.

Incident reports indicated that P1 ingested contraband items on two occasions during P1's second week of hospitalization. On 11/12/14 at 8:00 p.m., P1 broke off pieces of a plastic bathroom sign, ingested it, and later spit up some of the plastic pieces. On 11/18/14 at 6:00 p.m., P1 ingested a marker that got stuck in P1's throat. P1 was transferred to an acute care hospital where an endoscopic procedure was used to remove a pen cartridge from P1's upper esophagus.

There was no evidence that hospital staff reviewed the pattern of occurrences when P1 ingested contraband items that P1 accessed from the One-Up environment. There was no evidence that staff modified the environment or implemented any further measures to deter or prevent P1's ability to gain access to contraband items that posed danger to P1.

An incident report on 11/22/14 at 9:00 p.m. indicated that P1 was on top of the nurse's desk (approximately 4 feet in height) and swallowed a screw that P1 removed from the ceiling. An incident report on 11/28/14 at 3:07 p.m. indicated that P1 obtained a pen from a staff's pocket, who had breached the unit's safety protocol, but P1 gave the pen back to staff. On 11/30/14 at 1:15 a.m., P1 swallowed a pen.

There was no evidence that staff evaluated the One-Up environment to determine how to keep P1 safe, despite the ongoing incidents in which P1 was able to access contraband items in an environment that was allegedly designed to safeguard P1. During November 2014, P1 was on 1:1 distant staffing and was to be in staff's sight at all times.

An incident report on 01/02/15 at 2:06 a.m. indicated that P1 grabbed a pen from the nurse's office and swallowed it while staff was on the phone. Six minutes later, P1 pushed past staff in the nurse's office again and grabbed another pen.

An incident report on 01/25/15 at 10:00 p.m. indicated that P1 had inserted a three-inch piece of metal into her urethra. Although this was unwitnessed by staff, there was no evidence that staff made any effort to determine where P1 might have obtained the metal piece or searched the environment for sources of contraband items.

An incident report the next day on 01/26/15 at 7:50 p.m. indicated that P1 breeched the nursing office and removed a screw, a nail, and a hook from the wall in the nurse's office and swallowed them. Later that same shift, P1 broke two CD's and ingested 30 - 50 pieces of the CDs. In addition, P1 obtained a pen from the nurse's office and swallowed it shortly after she ingested the pieces of the broken CDs.

An incident report on 01/27/15 at 12:01 a.m. indicated that P1 moved a chair under a light fixture, removed the light bulb, smashed it, and swallowed two small pieces of glass.

An incident report on 01/28/15 at 7:00 p.m. indicated that P1 climbed onto a chair, opened a light fixture, broke the light bulb, and ingested parts of it. Although P1 had climbed onto a chair the previous day of 01/27/15 and ingested broken glass from a light bulb, staff failed to evaluate the environment on One-Up to prevent any similar reoccurrences. As a result, staff allowed P1 to climb onto another chair the next day of 01/28/15 and ingest glass from a light bulb that she broke. After ingesting glass on 01/28/15, P1 handed over to staff a nail, a pen, a screw, and a metal hook that she had hid in her room.

There was no evidence that staff conducted any contraband searches of P1's room or the One-Up environment to determine where and when P1 obtained contraband items that were supposed to be inaccessible to her. There was no evidence that staff initiated any measures to reduce P1's ability to access contraband, despite the ongoing occurrences of P1's ability to repeatedly obtain inedible substances that she ingested.

An incident report on 01/31/15 at 9:30 p.m. indicated that P1 pushed past staff in the nurse's office, grabbed the sharps container, removed a needle from a used syringe, and ran down the hall with the needle, swallowing it.

An incident report on 02/02/15 at 12:47 p.m. indicated that P1 had a pen in her bra which she ingested.

An incident report on 02/17/15 at 7:30 a.m. indicated that P1 reported to staff that she had inserted a metal spring into her abdomen "a few days ago" and could not take it out because it was stuck. Staff observed the metal object in her abdomen and the area of the puncture was red with drainage. P1 had a fever. P1 was transferred to an acute care hospital and was admitted to the intensive care unit with severe septic shock.

The history and physical from hospital #2 record, dated 02/18/15, indicated that the metal spring P1 had inserted into her abdomen was removed in the emergency room. P1 then underwent an endoscopic procedure that removed 3 pen cartridges from the stomach and a pencil from the duodenum. A scan showed a metal object in the abdomen. P1 underwent exploratory surgery of the abdomen where a piece of a hypodermic needle was found in the abdominal wall and a second piece of a hypodermic needle was found free-floating in P1's abdomen. P1 was "gravely ill." Due to P1's critical condition, P1 needed a higher level of acute care than could be provided at the local hospital. On 02/18/15, P1 was transferred to another hospital, hospital #3, 65 miles away, to meet P1's medical needs.

The history and physical from hospital #3 record dated 02/18/15, indicated that P1 had severe septic shock secondary to acute peritonitis with abdominal wall injury caused by a wire or a hypodermic needle. P1's condition of severe sepsis resulted in acute kidney injury which required hemodialysis. P1 also had acute hypoxic respiratory failure, hypervolemia, and aspiration pneumonia which required full ventilatory support. P1 remained hospitalized through 03/09/15.

RN Supervisor (RNS)/(B) was interviewed on 04/30/15 at 8:00 a.m. RNS/(B) stated that P1's behavior of self-harm was well-known to hospital staff from P1's previous inpatient admissions. Before P1 was admitted on 11/03/14, the hospital opened a closed unit called One-Up, to accommodate P1's needs for a highly structured setting. Prior to P1's arrival on 11/03/14, One-Up was sanitized by staff for of all items by that posed risks for potential ingestion by counter-sinking screws, making sure doors were locked for unauthorized rooms and locked cabinets that had supplies. P1 was the only patient on One-Up. The unit was staffed with 2 staff at all times to ensure P1 received 1:1 distant staffing which meant that P1 was to be in staff's sight 100% of the time.

RN Supervisor (RNS)/B was interviewed on 04/30/15 at 8:55 a.m. RNS/B stated that it was not determined how or where P1 obtained a pencil on 11/03/14 and ingested it. Pencils were one of the items removed from the One-Up environment because P1 was known to ingest them. Once a day, each morning at the start of the day-shift, nursing staff completed an environmental assessment of 24 items to ensure One-Up was a safe environment for P1. The written checklist included items such as ensuring doors were properly locked, no broken glass or sharp objects were in patient areas, ceiling tiles/vents/carpeting were intact, and hallways were clear of unnecessary items. The checklist did not include assessing the environment for any contraband items that posed specific danger to P1, such as pens, pins, earrings, badges, pencils, cell phones, pop cans, plastic med cups, or other small objects. RNS/B did not know if the One-Up environmental assessment was completed each time P1 obtained contraband items or ingested them or self-harmed in the One-Up environment, such as P1's ability to obtain and ingest a pencil within three hours of admission to One-Up.

RN/H was interviewed on 05/5/14 at 8:10 a.m. and stated she had H worked with P1 several times on One-Up. P1 obtained contraband items on One-Up, despite the environment being sanitized of inedible items that P1 preferred, such as pens. RN/H did not know how or where P1 obtained contraband, because P1's access was restricted to only certain rooms on One-Up and all of P1's programs were done on One-Up. P1 never left One-Up for any reason, other than to go to the emergency department after an incident of contraband ingestion. RN/H stated that contraband searches of the One-Up environment were not routinely done by staff, even after an incident when P1 had ingested contraband. RN/H thought some of P1's ingestion's were the result of staff letting their guard down and allowing P1 to be too close to an area where a restricted door was open, like the nurse's office.

RN/F was interviewed on 05/05/15 at 2:30 p.m. RN/F stated she knew P1 prior to 11/03/14. Before P1's admission on 11/03/14, staff were given education about unit modifications on One-Up to increase P1's safety. P1 was very manipulative and knowledgeable about how to access contraband. Two staff were always assigned on One-Up to afford 1:1 supervision of P1. RN/F was assigned to P1's care numerous times. P1 accessed contraband twice and ingested it, when P1 had two staff assigned to her including RN/F. RN/F did not know how or where P1 obtained the contraband.


RN/I was interviewed on 05/05/15 at 9:05 a.m. RN/I stated he seldom worked on One-Up with P1. RN/I was working during the shift when P1 ripped the fire panel off the wall and took a screw and nail from it. Although RN/I observed P1 remove the fire panel, RN/I did not observe P1 ingest the screw or nail but P1 told RN/I she ingested them. Sometime later that same shift, RN/I's co-worker told RN/I that P1 had broken 2 CDs and ingested pieces of it. No contraband search was done between the two incidents that shift. RN/I didn't think staff routinely conducted contraband searches. It's a nursing decision to initiate a contraband search to ensure environmental safety. RN/I stated he thought many of the nursing staff were afraid of P1, due to her size, body weight, and random incidents of physical aggression.

Psychiatrist/C was interviewed on 05/05/15 at 10:35 a.m. Psychiatrist/C stated that the priority for P1 was P1's safety in her environment. P1 was admitted to an environment sanitized of contraband items. P1's goal was to participate in behavior therapies to reduce the risk of P1 engaging in ingesting inedible items. P1 was restricted to three rooms on One-Up. P1's precautions and level of supervision were evaluated daily by a licensed psychiatrist. A specific Treatment Plan aimed at protecting P1 from self-injurious behavior was developed and implemented. Although Psychiatrist/C was aware that P1 had numerous incidents of inedible ingestion's, Psychiatrist/C did not specifically review each incident as it occurred. As a result, timely modifications to the Master Treatment Plan were not initiated regarding P1's repeated incidents of ingestion of inedible items. Psychiatrist/C stated that P1 was very good at creating diversions so she could blow by staff and get into a restricted area to obtain an ingestible.

RN/G was interviewed on 05/15/15 at 11:55 a.m. RN/G stated she worked with P1 on One-Up many times. Although the goal was to decrease the possibility of P1's ingestion's by providing a safe environment, P1 was still able to locate contraband in the environment and ingest it. P1 had 1:1 staffing and was always within staff's sight. Despite this, P1 was able to locate pens, screws, and other inanimate objects that P1 ingested in the One-Up environment. RN/G did not know how P1 obtained the contraband.

The hospital's policy Contraband and Program Safety, dated 04/07/15, indicated that a safe and therapeutic environment would be maintained for clients..."all facilities must prohibit the introduction and possession of contraband. Staff must have training in identifying contraband and conducting contraband searches. Staff is responsible for reporting the presence or suspected presence of contraband...probable cause (for a contraband search) exists when a staff member has reasonable suspicion, based on facts, circumstances, or other credible information that contraband, illegal or dangerous articles are in the possession of a client, or have been introduced into the facility...staff must collect the contraband and secure it in an appropriate location."

The hospital's policy Assessments and Treatment Planning, dated 08/25/14, indicated "Each child/adolescent will have a Master Treatment Plan developed on the basis of assessment results which includes an analysis of their unique strengths and needs. In developing a treatment plan, it is critical that there be logical progression from professional assessments to goals and objectives, to the development of and inclusion in treatment interventions and plans, and methods for ongoing review, reassessment, and reevaluation...the Master Treatment Plan will be updated as status changes."

Based on observation, interview, and document review, the hospital failed to ensure patients were free from abuse for 2 of 2 (P3) and (P4) reviewed, when staff used non-therapeutic and unauthorized physical restraints. P3 sustained bodily harm with multiple injuries to the face during the restraint procedure.

Findings include:

An incident report, dated 05/04/15, indicated that P3 was physically restrained by staff at 5:40 p.m., face-down on the floor in a prone restraint with pressure applied by two staff. Although the incident occurred on 05/04/15, the hospital did not immediately investigate the incident or protect patients from further potential incidents of abuse until a subsequent incident occurred four days later on 05/08/15. An incident report, dated 05/08/15, indicated that P4 was improperly restrained by staff at 6:30 p.m. when staff grabbed P4 by his arms and dragged P4 on his buttocks approximately 6 - 8 feet. The hospital did not immediately investigate the incident or protect patients from further potential incidents of abuse, until 05/11/15 when the hospital began investigating both the 05/04/11 and 05/08/11 incidents of improper restraints that were implemented in a punitive manner.

P3's Master Treatment Plan, dated 04/30/15, identified P3's target symptoms as hearing voices in which she was unable to respond to others, dissociating from reality, and becoming aggressive. P3's identified needs were a safe and structured environment, a reduction in aggression, and medication adjustment. P3's target behaviors occurred more often during evening hours. Staff were to provide P3 with wind-down time during the evening shift beginning at 3:15 p.m., to ensure the safety of everyone, including P3. Staff were to keep P3 in a quiet, low-activity environment, providing P3 with distraction and orientation to the present. Staff were to interact with P3 on a 1:1 basis using calming techniques, such as swaddling, tapping her arm, cloud squishes, stuffed animals, bath/shower, singing, cards, coloring, wearing her body sock, and eating oatmeal or M&M's

Observations on 05/11/15 of the hospital's video surveillance tapes for the 1-Down North unit, recorded on 05/04/15 at 5:40 p.m., indicated that P3 was physically restrained with multiple staff present during the improper procedure. None of the staff made any attempt to stop the unsafe restraint of P3. The videotape shows: P3 and P6 playing with a Frisbee in the 1-Down North unit hallway. Human Services Technician (HST)/P and P6 head toward the door that exits the unit. HST/P unlocks the door and holds it open to allow P6 to exit the unit. P6 exits and P3 races past HST/P into the foyer outside the unit's secured door. P3 is in the foyer for approximately 15 seconds with HST/P standing next to P3 holding the door open while P3 removes a screw from the door hinge, throws it on the floor, and then picks up the screw from the floor and keeps it in her hand. RN/F and HST/N are standing by the nurse's station, approximately 20 feet away. RN/F and HST/N go to the exit and escort P3 from the foyer into the unit. No physical contact with P3 is necessary. P3 follows staff back into the unit and walks toward the nurse's station. P3 has her hand to her mouth and is maneuvering a small object in her mouth with her fingers. P3 paces in the hall in front of the nurses's station. RN/F is behind the nurse's station counter. HST/N is in front of the nurse's station counter, several feet from P3. P3 takes a small object out of her mouth and throws it at RN/F. RN/F picks up the object from the floor and goes into the nurse's room. The nurse's room door closes. P3 approaches HST/N, who is still standing by the nurse's counter. P3 swipes at HST/N with an open hand but does not make any contact with HST/N. P3 again swipes at HST/N with an open hand at which time HST/N grabs P3's right arm and propels P3 downward toward the floor. P3's body strikes the wall as P3 spirals to the floor, face-first. P3 is against the wall in front of the nurse's station, on the floor in a prone position. HST/N has P3's right arm bent backwards behind P3's back. HST/N holds P3's right arm in place behind her back, while leaning in on P3 with his body positioned at P3's right side. P3's left arm is underneath her abdomen. RN/F comes out of the nurse's room and observes the physical restraint of P3. RN/F goes to the unit door and signals for help. RN/F returns to P3 and removes P3's shoes. P3 is moving her feet but is not kicking. HST/X arrives and positions himself at P3's feet. P3 is moving her feet but not kicking. HST/X places both of his arms around P3's lower legs and holds them. RN/F then positions herself at P3's head. P3 is trying to raise her head, but cannot move from HST/N's hold. RN/F dabs P3's face with tissues. There is obvious blood on the tissues. HST/O arrives, stands off to the side by the nurse's counter, and observes for approximately one minute. RN/K arrives, stands off to the side, and observes for approximately one minute. HST/O and RN/K leave the unit. RN/F, HST/N, and HST/X continue to restrain P3 for several additional minutes, during which time P3 is calm and makes several attempts to raise her head from the floor. Staff release P3 and P3 gets up from the floor. P3 was physically restrained in a prone position with two staff placing pressure on her torso and legs for 13 minutes.

HST/N was interviewed on 05/12/15 at 3:35 p.m. HST/N stated he was assigned to work on 1-Down South on 05/04/15. Around dinnertime, he went to 1-Down North to relieve another employee. When he arrived on 1-Down North, P3 was exhibiting manic behavior and was playing Frisbee with P6 in the hallway. Another employee attempted to disengage P6 from playing Frisbee, to calm P3 down. The employee took P6 off the unit. Only HST/N and RN/F remained on 1-Down North with P3 after the employee left with P6. HST/N, RN/F, and P3 were all standing near the nurse's station. P3 had obtained a screw from somewhere and had it in her hand. He saw P3 place the screw in her mouth. He asked P3 to remove the screw from her mouth and give it to him. P3 took the screw out of her mouth and threw it on the floor in the area between the nurse's counter and the nurse's office. RN/F picked up the screw and took it to the nurse's office. P3 was still manic and was ordering HST/N to "get off" the unit. P3 approached him and pushed him forcefully with both hands against his chest. He stepped back into a defensive position and put both of his hands up to guard himself from any further physical advances. He verbally cued her to calm down. P3 pushed him a second time in the same manner, with both hands against his chest. He took hold of her arm and they tripped. P3 fell to the floor and he fell on top of P3. P3's face hit the wall and carpet when P3 fell. P3 was in a prone position on the floor and he was positioned on the floor on P3's right side. He still had a hold of P3's right arm, which he restrained behind the center of P3's back, but P3's left arm was free. P3 yelled, "I'm bleeding." P3 was very upset and was yelling that she was going to punch HST/N's face. RN/F came to assist him within seconds. RN/F was present during the entire restraint procedure, which lasted 10 -15 minutes. When P3 was released from the restraint, P3 got up without any difficulty. He remained on 1-Down North for another ten minutes until RN/F gave the "all-clear" and he then returned to 1-Down South where he worked the remainder of his shift. HST/N was advised that the video does not show P3 pushing him forcefully with both hands, but rather shows P3 swiping at him with one open hand. In retrospect, HST/N stated he "jumped the gun" when he implemented the physical restraint. He realizes he should have stepped back, away from P3's space, to avoid the restraint, which would be consistent with the training he received. He was trained that a prone restraint can obstruct breathing and should only be used briefly in life-threatening situations. If ever it becomes necessary for staff to use a prone restraint, staff are trained to keep one of the patient's arms extended over the patient's head and to prop the patient up on one side by using staff's knees to support the patient's position. On 05/04/15, HST/N stated he "panicked."RN/(F) was interviewed on 05/12/15 at 10:05 a.m. RN/F stated she was assigned to work on 1-Down North on 05/04/15. P3 had been outside with P6 around 3:30 p.m. P3 was hyperactive, which is a precursor to P3's agitation. When they came back inside around 4:15 p.m., P3 was power-walking in the hallway, turning the lights on and off, and slamming doors. P3 and P6 were playing Frisbee in the hallway and staff were unable to re-direct P3 from the Frisbee game. Staff decided to separate P3 and P6, by removing P6 from the unit to another area for an activity. HST/P unlocked the unit door and held it open so P6 could exit. P3 immediately darted past HST/P into the foyer. P3 was not responding to HST/P's verbal negotiations for P3 to return to the unit. P3's verbalizations were very loud as P3 stood by the doorway. P3 removed a screw from the door frame and put it in her mouth. HST/N was working on the South unit, overheard P3's loud verbalizations, and arrived to assist. P3 was very resistive to HST/N's presence but P3 voluntarily walked back onto the North unit with HST/N. P3, HST/N, and RN/F were all standing near the nurse's counter. P3 kept asking if she could go to the activity room with P6 and when this was denied, P3 took a screw out of her mouth and threw it at RN/F. The screw hit RN/F's leg. RN/F picked up the screw and placed it in the locked nurse's room. When RN/F came out of the nurse's room, she did not see P3 or HST/N but she heard an interchange of words. RN/F proceeded to the front of the nurse's counter, where she observed HST/N holding P3 in a prone position on the floor. RN/F made observations that P3 was attempting to kick so RN/F removed P3's shoes. HST/N was holding one of P3's arms behind P3's back, but P3 could freely move the arm. P3's other arm was outstretched by her head. P3 was attempting to pinch, scratch, and bite HST/N. RN/F ran to the unit door and called for help. RN/F returned and positioned herself at P3's head. P3's nose was bleeding. HST/X arrived and manually held P3's legs. RN/F did not know if P3 was kicking, even though RN/F was positioned at P3's head and had a direct view of P3's legs. RN/F was concerned about P3's breathing. P3 has a history of asthma. P3 had shallow, labored respirations of 38 and the skin on P3's face was clammy. P3 was never rolled to her side during the physical restraint, despite RN/F's concern about P3's airway. P3 was kept in a prone position with one shoulder slightly elevated, for approximately 13 minutes. P3 was released from the restraint when she met verbal release criteria. After P3 got up off the floor, P3 had visible injuries to her face including an abrasion on her forehead above the right eyebrow, a bloody nose, a linear abrasion that extended from under the right nostril up across the right cheek to the outer corner of her right eye, and a swollen upper right lip.

RN/K was interviewed on 05/12/15 at 8:35 a.m. RN/K stated she was the assigned charge nurse during the evening shift of 05/04/15. RN/K was on 1-Down South at the time the physical restraint was implemented for P3 on 1-Down North. One of the staff notified her that P3 was restrained and they needed a physician's order for the restraint and an order for an intramuscular medication. When RN/K arrived on 1-Down South, she observed from the unit door entrance that P3 was restrained on the floor in a prone position. HST/N was positioned at P3's trunk on the right side. She did not notice that HST/N had P3's right arm bent behind her back. HST/X was bear-hugging P3's legs. RN/F was positioned at P3's head. She approached the scene with an oral medication. P3 was calm. P3 was released from the restraint and took the medication without incident. RN/K assessed P3, who had sustained injuries during the restraint. P3 had a 1-inch abrasion on her forehead, another abrasion that extended from her nose to her cheek which was weeping clear drainage, and her upper lip was swollen. An ice pack was applied. The areas continued to swell throughout the shift. She and RN/F completed an incident report and made all the necessary notifications to administration, the family, and county case worker. She didn't think there were any irregularities with P3's physical restraint. She stated it was RN/F's role to follow-up on any potential irregularities because RN/F was present during the restraint procedure.

HST/O was interviewed on 05/12/15 at 11:25 a.m. HST/O stated he was assigned to work on 1-Down South on 05/04/15. Around suppertime, RN/K told him to go to 1-Down North to provide assistance with a patient. When he arrived on the unit, P3 was restrained in a prone position on the floor. HST/N was on P3's right side. He did not notice that HST/N had P3's right arm bent backwards, restraining it behind her back. He noticed that P3's left arm was underneath her. HST/X was leaning across P3's legs, holding her legs. P3 was wiggling her toes, trying to kick her legs. RN/F was positioned at P3's head. P3 was yelling, "Get off me." HST/O checked to see if any of the staff were hurt or needed him to relieve them. He stayed about a minute and then went back to 1-Down South. He was surprised that staff didn't sound the panic alarm when engagement with P3 occurred, which is what staff are trained to do to ensure everyone's safety.

The statements of HST/N, RN/F, RN/K, and HST/O all conflicted with evidence on the hospital's video surveillance tape of what occurred during the incident.

There was no evidence that hospital staff recognized the breaches in safe practice that occurred during the physical restraint of P3 on 05/04/15. The hospital did not investigate the incident or take corrective action to prevent a similar occurrence. Four days later, on 05/08/15, an incident report revealed a subsequent event when staff improperly restrained P4.

P4's Master Treatment Plan, dated 04/30/15, identified P4's target symptom as aggression when P4 became angry or frustrated which was related to P4's inability to communicate his wants and needs to others. P4 has Autism and is nonverbal. P4's identified needs included development of a communication method to decrease P4's level of frustration and redirection/encouragement to help P4 stay on-task for more than a minute or so. Nursing staff were to provide P4 with 1:1 monitoring, a structured environment of sensory strategies, and a picture board/face cards as an aid to facilitate P4's ability to communicate some choices without aggression toward himself or others.

Observations on 05/11/15 of the hospital's video surveillance tapes for the 1-Down North unit, recorded on 05/08/15 at 6:30 p.m., indicated that P4 was physically restrained with two nurses present during the improper procedure. The videotape shows: P4 sits down on the floor on the 1-Down North unit, near the doorway that adjoins the 1-Down North unit and the 1-Down South unit. HST/M approaches P4. HST/M grabs a hold of P4's wrists. HST/M drags P4 by the arms with P4's arms extended straight backwards behind P4. HST/M drags P4 across the floor on his buttocks approximately 6 to 8 feet, through the doorway from the 1-Down North unit through the 1-Down South unit. LPN/L holds the door open while HST/M drags P4 through the doorway.

RN/K was interviewed on 05/12/15 at 8:35 a.m. RN/K stated she was the nurse assigned to work on 1-Down North on 05/08/15. LPN/L had brought P4 over to 1-Down North for awhile and when it was time for them to return to 1-Down South, P4 was noncompliant and sat down on the floor. LPN/L unlocked the door between the units. HST/M, who was working on 1-Down South, came through the door and grabbed P4's arms, pulled P4's arms behind him, and dragged P4 on his buttocks through the doorway to the South unit. By the time RN/K yelled to HST/M to "stop, you're going to hurt his arms," the incident was over. HST/M dragged P4 approximately 8 feet and then let go of him. RN/K immediately went over to the South unit to assess P4. P4's range of motion was intact and P4 had no marks on his buttocks from being dragged. RN/K spoke to HST/M and told him it was never appropriate to handle a patient in that manner. RN/K felt that the incident represented patient maltreatment so she filled out a Maltreatment Report and placed it in the Director's office (on a Friday evening) and faxed it to the State agency. RN/K did not consider that the maltreatment issue needed to be followed up immediately to protect patient safety. RN/K did not consider removing HST/M from patient contact because RN/F was the charge nurse and was aware of the incident.
LPN/L was interviewed on 05/12/15 at 11:40 a.m. LPN/L stated she held the door open between the units while HST/M and P4 came through the doorway on 05/08/15. LPN/L observed that P4 was sitting on the floor with his arms straight behind him and his legs straight out in front of him when P4 and HST/M passed through the doorway. HST/M was hanging onto P4 but LPN/L did not notice where HST/M had a hold of P4. LPN/L had never seen staff escort a patient by pulling on the patient while the patient was sitting on the floor. LPN/L reported and discussed this observation with RN/F who was the Charge nurse that shift.

RN/F was interviewed on 05/12/15 at 10:05 a.m. RN/F stated she immediately discussed what occurred during the 5/08/15 incident with HST/M and RN/K. HST/M denied that he had restrained P4 and indicated that P4 could have freed himself at any time. RN/K who had witnessed the incident thought HST/M's actions constituted maltreatment. RN/K assisted RN/F with completion of the written Maltreatment report. RN/F e-mailed Supervisor/B that the proper EASE (Effective and Safe Engagement) technique might not have been used with P4. RN/F did not consider removing HST/M from patient contact to protect patient safety. HST/M worked the remainder of the 05/08/15 shift, which was a Friday, and all weekend on 05/09/15 and 05/10/15.
HST/M was interviewed on 05/15/15 at 9:15 a.m. HST/M stated he was assigned to work on 1-Down South on 05/08/15. Around dinnertime, someone opened the door that adjoins 1-Down South and 1-Down North. P4 darted through the doorway. P4 then sat on the floor on 1-Down North and refused to comply with returning to 1-Down South. HST/M stated he performed a "modified escort" for P4's safety, in which HST/M grabbed P4 by the shoulders and P4 crab-walked on his buttocks. HST/M stated this modified escort was not taught in EASE training. HST/M just thought of it at the moment and doesn't know why he did it.

Treatment Director(TD)/A and RN Supervisor(RNS)/B were interviewed on 05/11/15 at 9:25 a.m. Both managers stated they learned of the 05/04/15 incident regarding the improper restraint of P3 on the morning of 05/05/15. HST/N had worked the remainder of his shift on 05/04/15 and for 2 hours on 05/11/15, before being removed from patient contact. As of 05/11/15, HST/N remained on an investigative suspension but neither TD/A nor RNS/B had further investigated the improper restraint of P3. TD/A and RNS/B had not interviewed other staff involved in the incident or taken any corrective action to prevent a similar occurrence, including re-education of staff, to ensure patient safety. Both managers stated they learned of the 05/08/15 incident regarding the improper restraint of P4 on the morning of 05/11/15. HST/M had worked the remainder of his shift on 05/08/15 as well as full shifts on 05/09/15 and 05/10/15. HST/M was removed from patient contact as of 05/11/15. Both managers were co-implementing investigations regarding both incidents, as of 05/11/15. No corrective action had been implemented as of 05/11/15 regarding staff's failure to recognize an improper restraint procedure, staff's failure to follow appropriate EASE techniques, and staff's failure to know and follow the appropriate procedures for incidents to ensure patient safety was protected.

The hospital's training course for EASE (Effective and Safe Engagement) Skills, Core Module 3: Physical Safety Strategies, dated September 30, 2013, indicated "Staff is authorized to use physical safety strategies only when clients, staff, or others are at imminent risk of harm in an emergency situation where all available, less restrictive methods have been unsuccessful in re-establishing safety. The application of physical safety strategies used to control or restrict the movements of a client is considered a restraint."

EASE Skills, Assess and Plan dated April 7, 2015 outlined approved physical safety strategies used with imminent risk of harm in an emergency situation that is used to control or restrict the movements of a client. They include verbal and non-verbal communication, balanced stance, positioning, movement, blocks, wrist releases, bite releases, front hair pull, hair pulls from behind, choke or shirt grasp from behind, front choke or shirt grasp, show of support, escort strategy one, escort strategy two, escort strategy three, arms crossed in front of person escort, securing a person in place, and group/team strategies for wrap and containment.

The EASE skills training program did not approve physical safety strategies by placing patients in a prone position or dragging a patient backwards by the arms.

The hospital's policy on Seclusion and Restraint, dated 12/09/14, indicated that a restraint could be initiated only on the authority of a licensed independent practitioner or RN who demonstrated competency in restraint application and safety interventions. The policy specified that "consideration of the child's/adolescent's dignity and privacy will be of highest priority...the minimum amount of intervention will be utilized for the shortest period of time to meet safety concerns."

The hospital's policy Incident Reporting and Management, dated 01/16/14, indicated "In order to protect the safety and well-being of clients and staff in State Operated Services (SOS) facilities, incidents must be managed, documented, reported, reviewed, and investigated in a timely manner utilizing a common approach."

The hospital's policy on Maltreatment of Minors-Protection, Reporting, and Investigation, dated 08/25/14, indicated that the responsibility of the program administrator was "ensuring that the internal reviews are completed, that the review of the report is documented and that corrective action is taken, if necessary, to protect the health and safety of the minors when either an external or internal report of alleged or suspected maltreatment of a minor has been made...the incident reviewer will review the incident the next working day...at a minimum, the internal review must include evaluation of whether related policies and procedures were followed, adequacy of policies and procedures, whether there is a need for additional staff training, whether there is a need for corrective action by the facility to protect the health and safety of the minor receiving care...CABHS must maintain documentation that the facility identified and took corrective action by implementing measures to reduce the risk of further errors or similar errors in therapeutic conduct."

Based on observation, interview, and document review, the hospital failed to ensure that patients were free from unnecessary restraints for 2 of 2 patients reviewed (P3 and P4), who were restrained by staff in an unapproved, unsafe manner. P3 sustained multiple injuries to the face during the restraint procedure.

Findings include:

P3's Master Treatment Plan, dated 04/30/15, identified P3's target symptoms as hearing voices in which she was unable to respond to others, dissociating from reality, and becoming aggressive. P3's identified needs were a safe and structured environment, a reduction in aggression, and medication adjustment. P3's target behaviors occurred more often during evening hours. Staff were to provide P3 with wind-down time during the evening shift beginning at 3:15 p.m., to ensure the safety of everyone, including P3. Staff were to keep P3 in a quiet, low-activity environment, providing P3 with distraction and orientation to the present. Staff were to interact with P3 on a 1:1 basis using calming techniques, such as swaddling, tapping her arm, cloud squishes, stuffed animals, bath/shower, singing, cards, coloring, wearing her body sock, and eating oatmeal or M&M's

Observations on 05/11/15 of the hospital's video surveillance tapes for the 1-Down North unit, recorded on 05/04/15 at 5:40 p.m., indicated that P3 was physically restrained with multiple staff present during the improper procedure. None of the staff made any attempt to stop the unsafe restraint of P3. The videotape shows: P3 and P6 playing with a Frisbee in the 1-Down North unit hallway. Human Services Technician (HST)/P and P6 head toward the door that exits the unit. HST/P unlocks the door and holds it open to allow P6 to exit the unit. P6 exits and P3 races past HST/P into the foyer outside the unit's secured door. P3 is in the foyer for approximately 15 seconds with HST/P standing next to P3 holding the door open while P3 removes a screw from the door hinge, throws it on the floor, and then picks up the screw from the floor and keeps it in her hand. RN/F and HST/N are standing by the nurse's station, approximately 20 feet away. RN/F and HST/N go to the exit and escort P3 from the foyer into the unit. No physical contact with P3 is necessary. P3 follows staff back into the unit and walks toward the nurse's station. P3 has her hand to her mouth and is maneuvering a small object in her mouth with her fingers. P3 paces in the hall in front of the nurses's station. RN/F is behind the nurse's station counter. HST/N is in front of the nurse's station counter, several feet from P3. P3 takes a small object out of her mouth and throws it at RN/F. RN/F picks up the object from the floor and goes into the nurse's room. The nurse's room door closes. P3 approaches HST/N, who is still standing by the nurse's counter. P3 swipes at HST/N with an open hand but does not make any contact with HST/N. P3 again swipes at HST/N with an open hand at which time HST/N grabs P3's right arm and propels P3 downward toward the floor. P3's body strikes the wall as P3 spirals to the floor, face-first. P3 is against the wall in front of the nurses' station, on the floor in a prone position. HST/N has P3's right arm bent backwards behind P3's back. HST/N holds P3's right arm in place behind her back, while leaning in on P3 with his body positioned at P3's right side. P3's left arm is underneath her abdomen. RN/F comes out of the nurse's room and observes at the physical restraint of P3. RN/F goes to the unit door and signals for help. RN/F returns to P3 and removes P3's shoes. P3 is moving her feet but is not kicking. HST/X arrives and positions himself at P3's feet. P3 is moving her feet but not kicking. HST/X places both of his arms around P3's lower legs and holds them. RN/F then positions herself at P3's head. P3 is trying to raise her head, but cannot move from HST/N's hold. RN/F dabs P3's face with tissues. There is obvious blood on the tissues. HST/O arrives, stands off to the side by the nurse's counter, and observes for approximately one minute. RN/K arrives, stands off to the side, and observes for approximately one minute. HST/O and RN/K leave the unit. RN/F, HST/N, and HST/X continue to restrain P3 for several additional minutes, during which time P3 is calm and makes several attempts to raise her head from the floor. Staff release P3 and P3 gets up from the floor. P3 was physically restrained in a prone position with two staff placing pressure on her torso and legs for 13 minutes.

HST/N was interviewed on 05/12/15 at 3:35 p.m. HST/N stated he was assigned to work on 1-Down South on 05/04/15. Around dinnertime, he went to 1-Down North to relieve another employee. When he arrived on 1-Down North, P3 was exhibiting manic behavior and was playing Frisbee with P6 in the hallway. Another employee attempted to disengage P6 from playing Frisbee, to calm P3 down. The employee took P6 off the unit. Only HST/N and RN/F remained on 1-Down North with P3 after the employee left with P6. HST/N, RN/F, and P3 were all standing near the nurse's station. P3 had obtained a screw from somewhere and had it in her hand. He saw P3 place the screw in her mouth. He asked P3 to remove the screw from her mouth and give it to him. P3 took the screw out of her mouth and threw it on the floor in the area between the nurse's counter and the nurse's office. RN/F picked up the screw and took it to the nurse's office. P3 was still manic and was ordering HST/N to "get off" the unit. P3 approached him and pushed him forcefully with both hands against his chest. He stepped back into a defensive position and put both of his hands up to guard himself from any further physical advances. He verbally cued her to calm down. P3 pushed him a second time in the same manner, with both hands against his chest. He took hold of her arm and they tripped. P3 fell to the floor and he fell on top of P3. P3's face hit the wall and carpet when P3 fell. P3 was in a prone position on the floor and he was positioned on the floor on P3's right side. He still had a hold of P3's right arm, which he restrained behind the center of P3's back, but P3's left arm was free. P3 yelled, "I'm bleeding." P3 was very upset and was yelling that she was going to punch HST/N's face. RN/F came to assist him within seconds. RN/F was present during the entire restraint procedure, which lasted 10 -15 minutes. When P3 was released from the restraint, P3 got up without any difficulty. He remained on 1-Down North for another ten minutes until RN/F gave the "all-clear" and he then returned to 1-Down South where he worked the remainder of his shift. HST/N was advised that the video does not show P3 pushing him forcefully with both hands, but rather shows P3 swiping at him with one open hand. In retrospect, HST/N stated he "jumped the gun" when he implemented the physical restraint. He realizes he should have stepped back, away from P3's space, to avoid the restraint, which would be consistent with the training he has received. He was trained that a prone restraint can obstruct breathing and should only be used briefly in life-threatening situations. If ever it becomes necessary for staff to use a prone restraint, staff are trained to keep one of the patient's arms extended over the patient's head and to prop the patient up on one side by using staff's knees to support the patient's position. On 05/04/15, HST/N stated he "panicked."RN/(F) was interviewed on 05/12/15 at 10:05 a.m. RN/F stated she was assigned to work on 1-Down North on 05/04/15. P3 had been outside with P6 around 3:30 p.m. P3 was hyperactive, which is a precursor to P3's agitation. When they came back inside around 4:15 p.m., P3 was power-walking in the hallway, turning the lights on and off, and slamming doors. P3 and P6 were playing Frisbee in the hallway and staff were unable to re-direct P3 from the Frisbee game. Staff decided to separate P3 and P6, by removing P6 from the unit to another area for an activity. HST/P unlocked the unit door and held it open so P6 could exit. P3 immediately darted past HST/P into the foyer. P3 was not responding to HST/P's verbal negotiations for P3 to return to the unit. P3's verbalizations were very loud as P3 stood by the doorway. P3 removed a screw from the door frame and put it in her mouth. HST/N was working on the South unit, overheard P3's loud verbalizations, and arrived to assist. P3 was very resistive to HST/N's presence but P3 voluntarily walked back onto the North unit with HST/N. P3, HST/N, and RN/F were all standing near the nurse's counter. P3 kept asking if she could go to the activity room with P6 and when this was denied, P3 took a screw out of her mouth and threw it at RN/F. The screw hit RN/F's leg. RN/F picked up the screw and placed it in the locked nurse's room. When RN/F came out of the nurse's room, she did not see P3 or HST/N but she heard an interchange of words. RN/F proceeded to the front of the nurse's counter, where she observed HST/N holding P3 in a prone position on the floor. RN/F made observations that P3 was attempting to kick so RN/F removed P3's shoes. HST/N was holding one of P3's arms behind P3's back, but P3 could freely move the arm. P3's other arm was outstretched by her head. P3 was attempting to pinch, scratch, and bite HST/N. RN/F ran to the unit door and called for help. RN/F returned and positioned herself at P3's head. P3's nose was bleeding. HST/X arrived and manually held P3's legs. RN/F did not know if P3 was kicking, even though RN/F was positioned at P3's head and had a direct view of P3's legs. RN/F was concerned about P3's breathing. P3 has a history of asthma. P3 had shallow, labored respirations of 38 and the skin on P3's face was clammy. P3 was never rolled to her side during the physical restraint, despite RN/F's concern about P3's airway. P3 was kept in a prone position with one shoulder slightly elevated, for approximately 13 minutes. P3 was released from the restraint when she met verbal release criteria. After P3 got up off the floor, P3 had visible injuries to her face including an abrasion on her forehead above the right eyebrow, a bloody nose, a linear abrasion that extended from under the right nostril up across the right cheek to the outer corner of her right eye, and a swollen upper right lip.

RN/K was interviewed on 05/12/15 at 8:35 a.m. RN/K stated she was the assigned Charge nurse during the evening shift of 05/04/15. RN/K was on 1-Down South at the time the physical restraint was implemented for P3 on 1-Down North. One of the staff notified her that P3 was restrained and they needed a physician's order for the restraint and an order for an intramuscular medication. When RN/K arrived on 1-Down South, she observed from the unit door entrance that P3 was restrained on the floor in a prone position. HST/N was positioned at P3's trunk on the right side. She did not notice that HST/N had P3's right arm bent behind her back. HST/X was bear-hugging P3's legs. RN/F was positioned at P3's head. She approached the scene with an oral medication. P3 was calm. P3 was released from the restraint and took the medication without incident. RN/K assessed P3, who had sustained injuries during the restraint. P3 had a 1-inch abrasion on her forehead, another abrasion that extended from her nose to her cheek which was weeping clear drainage, and her upper lip was swollen. An ice pack was applied. The areas continued to swell throughout the shift. She and RN/F completed an incident report and made all the necessary notifications to administration, the family, and county case worker. She didn't think there were any irregularities with P3's physical restraint. She stated it was RN/F's role to follow-up on any potential irregularities because RN/F was present during the restraint procedure.

HST/O was interviewed on 05/12/15 at 11:25 a.m. HST/O stated he was assigned to work on 1-Down South on 05/04/15. Around suppertime, RN/K told him to go to 1-Down North to provide assistance with a patient. When he arrived on the unit, P3 was restrained in a prone position on the floor. HST/N was on P3's right side. He did not notice that HST/N had P3's right arm bent backwards, restraining it behind her back. He noticed that P3's left arm was underneath her. HST/X was leaning across P3's legs, holding her legs. P3 was wiggling her toes, trying to kick her legs. RN/F was positioned at P3's head. P3 was yelling, "Get off me." HST/O checked to see if any of the staff were hurt or needed him to relieve them. He stayed about a minute and then went back to 1-Down South. He was surprised that staff didn't sound the panic alarm when engagement with P3 occurred, which is what staff are trained to do to ensure everyone's safety.

The statements of HST/N, RN/F, RN/K, and HST/O all conflicted with evidence on the hospital's video surveillance tape of what occurred during the incident.

There was no evidence that hospital staff recognized the breaches in safe practice that occurred during the physical restraint of P3 on 05/04/15. The hospital did not investigate the incident or take corrective action to prevent a similar occurrence. Four days later, on 05/08/15, an incident report revealed a subsequent event when staff improperly restrained P4.

P4's Master Treatment Plan, dated 04/30/15, identified P4's target symptom as aggression when P4 became angry or frustrated which was related to P4's inability to communicate his wants and needs to others. P4 has Autism and is nonverbal. P4's identified needs included development of a communication method to decrease P4's level of frustration and redirection/encouragement to help P4 stay on-task for more than a minute or so. Nursing staff were to provide P4 with 1:1 monitoring, a structured environment of sensory strategies, and a picture board/face cards as an aid to facilitate P4's ability to communicate some choices without aggression toward himself or others.

Observations on 05/11/15 of the hospital's video surveillance tapes for the 1-Down North unit, recorded on 05/08/15 at 6:30 p.m., indicated that P4 was physically restrained with two nurses present during the improper procedure. The videotape shows: P4 sits down on the floor on the 1-Down North unit, near the doorway that adjoins the 1-Down North unit and the 1-Down South unit. HST/M approaches P4. HST/M grabs a hold of P4's wrists. HST/M drags P4 by the arms with P4's arms extended straight backwards behind P4. HST/M drags P4 across the floor on his buttocks approximately 6 to 8 feet, through the doorway from the 1-Down North unit to the 1-Down South. LPN/L holds the door open while HST/M drags P4 through the doorway.

RN/K was interviewed on 05/12/15 at 8:35 a.m. RN/K stated she was the nurse assigned to work on 1-Down North on 05/08/15. LPN/L had brought P4 over to 1-Down North for awhile and when it was time for them to return to 1-Down South, P4 was noncompliant and sat down on the floor. LPN/L unlocked the door between the units. HST/M, who was working on 1-Down South, came through the door and grabbed P4's arms, pulled P4's arms behind him, and dragged P4 on his buttocks through the doorway to the South unit. By the time RN/K yelled to HST/M to "stop, you're going to hurt his arms," the incident was over. HST/M dragged P4 approximately 8 feet and then let go of him. RN/K immediately went over to the South unit to assess P4. P4's range of motion was intact and P4 had no marks on his buttocks from being dragged. RN/K spoke to HST/M and told him it was never appropriate to handle a patient in that manner. RN/K felt that the incident represented patient maltreatment so she filled out a Maltreatment Report and placed it in the Director's office (on a Friday evening) and faxed it to the State agency. RN/K did not consider that the maltreatment issue needed to be followed up immediately to protect patient safety. RN/K did not consider removing HST/M from patient contact because RN/F was the Charge nurse and was aware of the incident.
LPN/L was interviewed on 05/12/15 at 11:40 a.m. LPN/L stated she held the door open between the units while HST/M and P4 came through the doorway on 05/08/15. LPN/L observed that P4 was sitting on the floor with his arms straight behind him and his legs straight out in front of him when P4 and HST/M passed through the doorway. HST/M was hanging onto P4 but LPN/L did not notice where HST/M had a hold of P4. LPN/L had never seen staff escort a patient by pulling on the patient while the patient was sitting on the floor. LPN/L reported and discussed this observation with RN/F who was the Charge nurse that shift.

RN/F was interviewed on 05/12/15 at 10:05 a.m. RN/F stated she immediately discussed what occurred during the 5/08/15 incident with HST/M and RN/K. HST/M denied that he had restrained P4 and indicated that P4 could have freed himself at any time. RN/K who had witnessed the incident thought HST/M's actions constituted maltreatment. RN/K assisted RN/F with completion of the written Maltreatment report. RN/F e-mailed Supervisor/B that the proper EASE (Effective and Safe Engagement) technique might not have been used with P4. RN/F did not consider removing HST/M from patient contact to protect patient safety. HST/M worked the remainder of the 05/08/15 shift, which was a Friday, and all weekend on 05/09/15 and 05/10/15.
HST/M was interviewed on 05/15/15 at 9:15 a.m. HST/M stated he was assigned to work on 1-Down South on 05/08/15. Around dinnertime, someone opened the door that adjoins 1-Down South and 1-Down North. P4 darted through the doorway. P4 then sat on the floor on 1-Down North and refused to comply with returning to 1-Down South. HST/M stated he performed a "modified escort" for P4's safety, in which HST/M grabbed P4 by the shoulders and P4 crab-walked on his buttocks. HST/M stated this modified escort was not taught in EASE training. HST/M just thought of it at the moment and doesn't know why he did it.

Treatment Director(TD)/A and RN Supervisor(RNS)/B were interviewed on 05/11/15 at 9:25 a.m. Both managers stated they learned of the 05/04/15 incident regarding the improper restraint of P3 on the morning of 05/05/15. HST/N had worked the remainder of his shift on 05/04/15 and for 2 hours on 05/11/15, before being removed from patient contact. As of 05/11/15, HST/N remained on an investigative suspension but neither TD/A nor RNS/B had further investigated the improper restraint of P3. TD/A and RNS/B had not interviewed other staff involved in the incident or taken any corrective action to prevent a similar occurrence, including re-education of staff, to ensure patient safety. Both managers stated they learned of the 05/08/15 incident regarding the improper restraint of P4 on the morning of 05/11/15. HST/M had worked the remainder of his shift on 05/08/15 as well as full shifts on 05/09/15 and 05/10/15. HST/M was being removed from patient contact as of 05/11/15. Both managers were co-implementing investigations regarding both incidents, as of 05/11/15. No corrective action had been implemented as of 05/11/15 regarding staff's failure to recognize an improper restraint procedure, staff's failure to follow appropriate EASE techniques, and staff's failure to know and follow the appropriate procedures for incidents to ensure patient safety was protected.

The hospital's training course for EASE (Effective and Safe Engagement) Skills, dated 04/30/15, indicated "Staff is authorized to use physical safety strategies only when clients, staff, or others are at imminent risk of harm in an emergency situation where all available, less restrictive methods have been unsuccessful in re-establishing safety. The application of physical safety strategies used to control or restrict the movements of a client is considered a restraint."

The hospital's policy on Seclusion and Restraint, dated 12/09/14, indicated that a restraint could be initiated only on the authority of a licensed independent practitioner or RN who demonstrated competency in restraint application and safety interventions. The policy specified that "consideration of the child's/adolescent's dignity and privacy will be of highest priority...the minimum amount of intervention will be utilized for the shortest period of time to meet safety concerns."

The hospital's policy Incident Reporting and Management, dated 01/16/14, indicated "In order to protect the safety and well-being of clients and staff in State Operated Services (SOS) facilities, incidents must be managed, documented, reported, reviewed, and investigated in a timely manner utilizing a common approach."

The hospital's policy on Maltreatment of Minors-Protection, Reporting, and Investigation, dated 08/25/14, indicated that the responsibility of the program administrator was "ensuring that the internal reviews are completed, that the review of the report is documented and that corrective action is taken, if necessary, to protect the health and safety of the minors when either an external or internal report of alleged or suspected maltreatment of a minor has been made...the incident reviewer will review the incident the next working day...at a minimum, the internal review must include evaluation of whether related policies and procedures were followed, adequacy of policies and procedures, whether there is a need for additional staff training, whether there is a need for corrective action by the facility to protect the health and safety of the minor receiving care...CABHS must maintain documentation that the facility identified and took corrective action by implementing measures to reduce the risk of further errors or similar errors in therapeutic conduct."

Based on interview and document review, the hospital failed to ensure a process for quality assessment and performance improvement activities that reflect the need for patient safety and enhanced health outcomes when providing treatment for behavioral symptoms, for 1 of 7 patients reviewed, who ingested inedible items obtained from the hospital enviroment hospital or inflicted self-harm that resulted in adverse events.

The findings include:The failure to ensure the Quality Assessment and Performance Improvement Committee had a process to identify quantitative and qualitative measures of the hospitals complexity to provide a safe enviroment when treating individuals for behavior symptoms resulted in the hospitals inability to determine quality assessment measures and implement improvement activities. Therefore, the hospital was unable to meet the Condition of Participation: Quality Assessment and Performance Improvement Program at 42 CFR 428.21.

These deficient practices had the potential to affect all patients receiving services at the hospital.

Based on interview and document review the hospital failed to ensure performance improvement activities reflected the high risk, high volume incidents of self-harm behaviors for 1 of 10 patients reviewed when a patient, (P1), developed septic shock after obtaining contraband items that the patient either ingested or inserted into her body as well as tying items around her neck. (A283)

Based on interview and document review the behavior health hospital failed to measure, analyze and track preventable adverse events involving patient safety for 1 of 10 patients reviewed, when a patient, (P1), developed septic shock after obtaining contraband items that P1 either ingested or inserted into her body. (A286)

Based on interview and document review the hospital failed to ensure performance improvement activities reflected the high risk, high volume incidents of self-harm behaviors for 1 of 10 patients reviewed when a patient, (P1), developed septic shock after obtaining contraband items that the patient either ingested or inserted into her body as well as tying items around her neck.

The findings include:

P1's incident reports from 11/3/14 to 2/17/15 were reviewed. P1 had high risk and high volume incidents. P1 was sent to a hospital emergency room 6 times to remove foreign object that were ingested. The incidents indicated they were part of a pattern. Three were listed as a serious incident by the hospital. P1's self-injurious behavior and/or ingested items included: pencils, pens, batteries, plastic parts, screws, compact disc, light bulb glass, hypodermic needle, and metal objects. P1's incidents included approximately: self-injurious behavior/deliberate self-harm 25 times, ingestion of a foreign object (or substance) 15 times, patient aggression to staff 7 times, property damage 6 times, injury from equipment, behavioral intervention actives of daily living 1 times, possession/use of contraband 13 time, physical assault 3 time.

The hospital had high risk and high volume incidents. The hospital incident report summary from 11/6/14 to 5/11/15 was reviewed. The hospital had data on 15 patients, 10 of the patients were in the sample. P1's data is not included in this summary. Therefore, the reviewed data was comprised of 14 patients. None were considered were listed as a serious incident by the hospital. The hospital incidents included approximately: aggression towards staff 41 times, self-injurious behavior, deliberate self-harm 13 times, verbal/non-verbal threats 5 times, property damage 4 times, injury from equipment/behavioral intervention actives of daily living 4 times, physical assault appeared 4 times, sexual 3 times, falls/slips/found on the floor/ground 3 times, possession/ use of contraband 1 time, ingestion of a foreign object (or substance) 1 time, physical health 1 time, aggression individual 2 times.

Safety/Infection Committee meeting minutes were reviewed for 11/14/14, 12/8/14, 1/12/15, 2/9/15, 3/23/15, and 4/13/15 there were an approximate total of 108 incidents of patient safety and significant events. There was no specific data provided for the nature of injuries or if any were considered serious, there was no recommended action, and the target dates were continually on going.
The hospital Quality Assessment/Performance Improvement (QA/PI) meeting minutes for 10/29/14, 3/23/15 and 4/28/15 (there were no QA/PI meetings scheduled for the months of November 2014, December 2014, January 2015, or February 2015), did not focus on incidents of high risk, high volume, or problem prone areas. P1's adverse events were not included in the QA/PI meeting minutes. Nor did it reflect recommendations and/or data collected from the hospital Registered Nurse Meetings, Incident Reporting Statistics, or the Safely/Infection Committee data on infection control, safety/risk management of patient incidents and significant events, assessments environmental health and safety rounds, security, hazardous material/waste, emergency preparedness, fire prevention, medical equipment and utilities.

Medical Director (MD)/C was interviewed on 5/12/15 at approximately 1:45 p.m. and indicated the hospital uses data to study trends and determine how to improve processes. Leadership reviews data from the Safety/Infection Committee.

The Director and Nursing Supervisor were interviewed on 5/13/15 at approximately 8:40 a.m. and indicated the hospital collects data of the core measures of accredited organization and four that are specific to the hospital related to medical errors, psychiatric assessment documentation, history and physical documentation and critical lab values. The goal of the hospital is to increase safety of the patients by increasing staff awareness of high-risk behaviors. A summary of the incident report is sent to CQO/Q to review for adverse events for a second check to make sure we are reporting correctly.

Chief Quality Officer for Direct Care and Treatment Support Performance Improvement Staff Health and Safety Infection Control (CQO)/Q was interviewed on 5/14/15 at approximately 12:34 p.m. and indicated the hospital quality indicators are brought forth by the hospital and approved by the governing board annually and may be set measures for other issues as the need arises. Three of the four quality indicators are related to areas of documentation. CQO/Q indicated only incident reports marked as significant or major incidents are reviewed by her to bring to the governing board for action. A significant or major incident report would include an emergency room hospital visit, an elopement, and injury during a seclusion or restraint, or and attempted or successful suicide. Incidents that do not meet a major incident are not reported to the Governing Board. CQO/Q indicated she would not know if a hospital or patient had repeated incidents of the same type unless the Safety/Infection Committee who collects that data or a staff person would approach her with a concern reported it to her. State Operated Services Governance Structure Charter, not dated, indicated the team monitors and ensures the highest quality of care to person receiving services from state operated services, regularly reviews standardized measures of consumer treatment outcomes from each state operated services component and implement quality/performance improvements as necessary and oversees quality and patient safety activities through existing reporting structure.

Based on interview and document review the behavior health hospital failed to measure, analyze and track preventable adverse events involving patient safety for 1 of 10 patients reviewed, when a patient, (P1), developed septic shock after obtaining contraband items that P1 either ingested or inserted into her body.

The findings include:

The facility policy titled Administration Adverse Healthcare Events Reporting, dated 4/7/15, effective 5/5/15, policy number 2025 defined adverse health event as one of the twenty-nine reportable events defined under State law. Patient Protection Events: patient suicide, attempted suicide resulting in serious injury, or self-harm resulting in serious injury or death while being care for in a facility due to patient actions after admission to the facility, excluding deaths resulting from self-inflicted injuries that were the reason for admission to the facility.

P1's incidents were reviewed from 11/3/14 to 2/17/15 for adverse events. The following incidents demonstrated self-harm and/or suicide attempts that resulted in serious injury/illness:
o 11/3/14 at 6:45 p.m. P1 found, broke, and ingested parts of a pencil. P1 was taken to a hospital emergency room where an x-ray of the upper gastrointestinal tract found an ink pen, two batteries, but did not reveal pencil parts. P1 was sent back to the hospital to be monitored and wait for the items to pass through her gastrointestinal tract.
o 11/5/14 at 10:50 p.m. P1 told staff she an ingested a foreign object, a phone battery. P1 was taken to a hospital emergency room. P1 was hospitalized to monitor the gastrointestinal tract for the swallowed items that should pass with a bowel movement.
o 11/7/14 at 11:00 p.m. P1 told staff she ingested a foreign object, an ink pen cartridge, and a spring from a pen. P1 was taken to a hospital emergency room where the consumed items were removed endoscopically.
o 11/9/14 at 7:20 p.m., P1 told staff she ingested a foreign object, a pencil. P1 was taken to a hospital emergency room where an x-ray found a pen in the lower esophageal area, an ink pen spring in her lower colon and no evidence of a pencil. The consumed pen was removed endoscopically.
o 11/18/14 at 6:00 p.m. P1 ingested a marker that was stuck in P1's throat. P1 was taken to a hospital emergency room where the consumed marker was removed endoscopically.
o 1/20/15 at 5:30 a.m., P1 punctured right upper forearm (unknown object) and wrapped a sweatshirt around her neck three times causing her face to turn blue.
o 1/25/15 at 11:45 p.m. P1 tied an object around her neck, her face was pink, and blue mottled.
o 1/26/15 at 7:50 p.m., P1 entered the nursing office, took an item from the wall obtaining a screw, nail, and metal hook, and then ingested those items. P1 also broke a compact disc into pieces and told staff she swallowed approximately 30 or more pieces, as well as a pen she obtained from the nursing office. P1 did complain of abdominal, throat and chest pain, and difficulty breathing.
o 2/17/15 at 7:30 a.m. P1 told staff, she inserted a metal spring in her stomach a few days ago and could not take it out because it was stuck. Staff viewed the metal object in her abdomen; the area of the puncture was red with drainage. P1 was sent to a hospital emergency room and was admitted to the intensive care unit for septic shock.

Safety/Infection Committee meeting minutes were reviewed for 11/14/14, 12/8/14, 1/12/15, 2/9/15, 3/23/15, and 4/13/15 there were an approximate total of 108 incidents of patient safety and significant events. There was no specific data provided for the nature of injuries or if any were considered serious, there was no recommended action, and the target dates were continually on going.

The hospital Quality Assessment/Performance Improvement (QA/PI) meeting minutes for 10/29/14, 3/23/15 and 4/28/15 (there were no QA/PI meetings scheduled for the months of November 2014, December 2014, January 2015, or February 2015), did not measure, analyze and track preventable adverse events. P1's adverse events were not included in the QA/PI meeting minutes. Nor did it reflect recommendations and/or data collected from the hospital Registered Nurse Meetings, Incident Reporting Statistics, or the Safely/Infection Committee data on infection control, safety/risk management of patient incidents and significant events, assessments environmental health and safety rounds, security, hazardous material/waste, emergency preparedness, fire prevention, medical equipment and utilities.

Medical Director (MD)/C was interviewed on 5/12/15 at approximately 1:45 p.m. and indicated he reviews all of the critical incidents such as elopement, suicide attends, physical injuries and maltreatment.

Chief Quality Officer for Direct Care and Treatment Support Performance Improvement Staff Health and Safety, Infection Control(CQO)/Q was interviewed on 5/14/15 at approximately 12:34 p.m. and indicated the hospital quality indicators are brought forth by the hospital and approved by the governing board annually and may be set measures for other issues as the need arises. Three of the four quality indicators are related to areas of documentation. CQO/Q indicated only incident reports marked as significant or major incidents are reviewed by her to bring to the governing board for action. A significant or major incident report would include an emergency room hospital visit, an elopement, and injury during a seclusion or restraint, or and attempted or successful suicide. Incidents that do not meet a major incident are not reported to the Governing Board. CQO/Q indicated she would not know if a hospital or patient had repeated incidents of the same type unless the Safety/Infection Committee who collects that data or a staff person would approach her with a concern reported it to her.
The facility policy titled Administration Incident Reporting and Management, policy number 2020 dated 1/16/14, indicated a major incident is an occurrence that may have a major negative impact on clients, visitors, employees, programs or the department. A major incident include death, elopement, serious injury or illness, physical assault, homicide attempt, sexual assault, a significant business interruption or other situations at the discretion of the local authority. A major incident is automatically messaged to the program leadership and executive team. All incidents are electronically sent to the administrative reviewer. The administrative reviewer determines if they type of incident should remain at the same status, if further assessment is required and determine the type of assessment in consultation with the State Operated Services Risk Management Supervisor.
State Operated Services Governance Structure Charter, not dated, indicated the team monitors and ensures the highest quality of care to person receiving services from state operated services, regularly reviews standardized measures of consumer treatment outcomes from each state operated services component and implement quality/performance improvements as necessary and oversees quality and patient safety activities through existing reporting structure.

Based on observation, interview, and document review, the hospital failed to ensure patient care was supervised in a manner that provided a safe patient treatment environment, for 3 of 5 patient reviewed, who required 1:1 monitoring due to behavioral symptoms of aggression, noncompliance, and pica.

The findings include:

The hospital did not meet the Condition of Participation of Nursing Services at 42 CFR 482.23. These deficient practices had the potential to impact all patients.

The hospital administrative staff was notified they were in an immediate jeopardy (IJ) on 5/11/15 at 5:30 p.m. when they failed to ensure adequate supervision of P1 who was able to obtain contraband, ingested inedible items or inserted items, and developed septic shock that required hospitalization at another hospital for approximately 20 days. The IJ began on 5/3/15 when the hospital failed to ensure adequate supervision and failure to obtain nurse authorization of a physical restraint prior to the implementation of a restraint by an unlicensed staff. The restraint that was initiated was an unapproved prone restraint. The hospital's failure to identify adequate supervision resulted in another unauthorized restraint to a second patient.

The hospitals established protocols for a Registered Nurse to authorize the use of seclusion or restraint as necessary and direct the action of the staff, and to provide a safe and therapeutic treatment enviroment had not been implemented when P3 and P4's were restrained by unlicensed personnel and the restraint procedure was not directed when a Registered Nurse was present, and adequate supervise to provide a safe enviroment for the therapeutic treatment of behavioral symptoms despite P1's "sanitized" enviroment P1 still obtained contraband, ingested or inserted items, and developed septic shock that required an acute care hospital stay of approximately 20 days.

The severity and cumulative effect of these system failures resulted in the hospital's inability to ensure that individualized patient care needs were implemented safely in accordance with the hospital's established policies, procedures, and protocols pertaining to restraints and environmental contraband. Therefore, the hospital was unable to meet the Condition of Participation of Nursing Services at 42 CFR 482.23.

The IJ was removed on 5/15/15 at 11:30 a.m. when an acceptable removal plan was implemented to protect the health and safety of patients. Interviews and document review verified and established that the hospitals leadership had begun a reeducation process for Effective and Safe Engagement Skills (EASE) an 8 hour training to be completed by 5/22/15 by all staff, immediately reeducated the Charge Registered Nurses on seclusion/restraints and incident management. The Director, Registered Nurse Supervisor, and a Registered Nurse Senior provided supervision on the units from 6:00 a.m. to 9:00 p.m., seven days a week through 5/31/15 to ensure staff were properly utilizing established protocols, and began the internal investigation process of the incidents of P3 and P4.

These deficient practices had the potential to impact all patients receiving services at the hospital.

Based on observation, interview and document review the facility failed to ensure a nurse authorized the physical restraint prior to the initiation by an unlicensed staff who initiated and used unapproved physical restraint procedures for two of three patients reviewed, (P3) and (P4), and failed to adequately supervise a patient with pica behaviors for one of three patients reviewed, (P1), who developed septic shock after obtaining items in the environment that were either ingested or inserted into her body as well as tying items around her neck. (A392)

Based on observation, interview and document review the facility failed to ensure a nurse authorized the physical restraint prior to the initiation by an unlicensed staff who initiated and used unapproved physical restraint procedures for two of three patients reviewed, (P3) and (P4), and failed to adequately supervise a patient with pica behaviors for one of three patients reviewed, (P1), who developed septic shock after obtaining items in the environment that were either ingested or inserted into her body as well as tying items around her neck.

The facility policy titled Client Care Seclusion and Restraint dated 12/9/14, Procedure Number 13309 indicated a physical restraint is any manual method that immobilizes or reduces the ability of a client to move arms, body, or head freely. The hospital uses seclusion or restraint only to protect the immediate physical safety of the client, staff or others. The hospital uses seclusion or restraint only when less restrictive interventions are ineffective. The Registered Nurse who demonstrates current competence in the seclusion and restraint, therapeutic intervention may authorize the use of seclusion or restraint as necessary and directs the action of the staff to assure that the procedure is followed. Staff are to demonstrate competencies in prevention of and/or alternatives to restraint, applications of restraints, implementation of seclusion, assessment of clients in seclusion or restraint, and providing care to a client in seclusion or restraint.

P3's hospital record was reviewed. P3's Master Treatment Plan, dated 04/30/15, identified P3's target symptoms as hearing voices in which she was unable to respond to others, dissociating from reality, and becoming aggressive. Staff were to interact with P3 on a 1:1 basis using calming techniques, such as swaddling, tapping her arm, cloud squishes, stuffed animals, bath/shower, singing, cards, coloring, wearing her body sock, and eating oatmeal or M&M's.

Observations on 05/11/15 of the hospital's video surveillance tapes for the 1-Down North unit, recorded on 05/04/15 at 5:40 p.m., indicated that P3 was physically restrained with multiple staff present. P3 was physically restrained in a prone position with two staff placing pressure on her torso and legs for 13 minutes. None of the staff made any attempt to stop the unsafe restraint of P3. The videotape showed: P3 swipe at HST/N with an open hand with no contact. P3 swiped a second time at HST/N with an open hand at which time HST/N grabs P3's right arm and propels P3 to the floor. P3's body strikes the wall as P3 spirals to the floor, face-first. P3 is against the wall in front of the nurses' station, on the floor in a prone position. HST/N has P3's right arm bent backwards behind P3's back, leaning in on P3's right side. P3's left arm is underneath her abdomen. RN/F comes out of the nurse's room and observes at the physical restraint of P3. RN/F goes to the unit door and signals for help. HST/X arrives and positions himself at P3's feet to hold them. RN/F then positions herself at P3's head to remove blood from the injury. P3 is trying to raise her head, but cannot move from HST/N's hold. HST/O and RN/K arrive and observe for approximately one minute then leave the unit. RN/F, HST/N, and HST/X continue to restrain P3 for several additional minutes, during which time P3 is calm and makes several attempts to raise her head from the floor. Staff release P3 and P3 gets up from the floor.

HST/N was interviewed on 05/12/15 at 3:35 p.m. and indicated if ever it becomes necessary for staff to use a prone restraint, staff are trained to keep one of the patient's arms extended over the patient's head and to prop the patient up on one side by using staff's knees to support the patient's position. HST/N indicated when P3 pushed him a second time he took hold of her arm and they tripped. P3 fell to the floor, hit her face to the wall and the floor and he on top of P3. P3 was in a prone position on the floor and he was positioned P3's right side holding her right arm at the center of P3's back. P3 was very upset and yelled, "I'm bleeding." RN/F came to assist him within seconds. HST/N stated he "jumped the gun" when he implemented the physical restraint that lasted 10-15 minutes. RN/F was present during the entire restraint procedure.RN/(F) was interviewed on 05/12/15 at 10:05 a.m. and stated when she came out of the nurse's room, she did not see P3 or HST/N, but heard an interchange of words. RN/F proceeded to the front of the nurse's counter, where she observed HST/N had restrained P3 in a prone position on the floor with one of P3's arms behind her back. RN/F positioned herself at P3's head and P3 had visible injuries to her face. P3's nose was bleeding. RN/F was concerned about P3's breathing. P3 had shallow, labored respirations of 38 and the skin on P3's face was clammy. RN/F indicated she did not instruct staff to roll P3 to her side during the physical restraint. P3 was kept in a prone position before being released.

RN/K was interviewed on 05/12/15 at 8:35 a.m. and stated she was the assigned charge nurse during the evening shift of 05/04/15. RN/K was on a different unit at the time the physical restraint was implemented for P3 but was told by a staff that P3 was restrained. When RN/K arrived she observed from the unit door entrance that P3 was restrained on the floor in a prone position. RN/K retrieved oral medication for P3 and when she arrived during the restraint RN/F was positioned at the head of P3. P3 was calm. P3 was released from the restraint and took the medication without incident. RN/K stated it was RN/F's role to follow-up on any potential irregularities because RN/F was present during the restraint procedure.

P4's hospital record was reviewed. P4's Master Treatment Plan, dated 04/30/15, identified P4's target symptom as aggression when P4 became angry or frustrated which was related to P4's inability to communicate his wants and needs to others. P4 has Autism and is nonverbal. P4's identified needs included development of a communication method to decrease P4's level of frustration and redirection/encouragement to help P4 stay on-task for more than a minute or so. Nursing staff were to provide P4 with 1:1 monitoring, a structured environment of sensory strategies, and a picture board/face cards as an aid to facilitate P4's ability to communicate some choices without aggression toward himself or others.

Observations on 05/11/15 of the hospital's video surveillance tapes for the 1-Down North unit, recorded on 05/08/15 at 6:30 p.m., indicated that P4 was physically restrained with two nurses present during the improper procedure. The videotape shows: P4 sits down on the floor on the 1-Down North unit, near the doorway that adjoins the 1-Down North unit and the 1-Down South unit. HST/M approaches P4. HST/M grabs a hold of P4's wrists. HST/M drags P4 by the arms with P4's arms extended straight backwards behind P4. HST/M drags P4 across the floor on his buttocks approximately 6 to 8 feet, through the doorway from the 1-Down North unit to the 1-Down South. LPN/L holds the door open while HST/M drags P4 through the doorway.

RN/K was interviewed on 05/12/15 at 8:35 a.m. and stated she was the nurse assigned to work on 1-Down North on 05/08/15. LPN/L had brought P4 over to 1-Down North for awhile and when it was time for them to return to 1-Down South, P4 was noncompliant and sat down on the floor. LPN/L unlocked the door between the units. HST/M, who was working on 1-Down South, came through the door and grabbed P4's arms, pulled P4's arms behind him, and dragged P4 on his buttocks through the doorway to the South unit. By the time RN/K yelled to HST/M to "stop, you're going to hurt his arms," the incident was over. HST/M dragged P4 approximately 8 feet and then let go of him. RN/K immediately went over to the South unit to assess P4. P4's range of motion was intact and P4 had no marks on his buttocks from being dragged. RN/K spoke to HST/M and told him it was never appropriate to handle a patient in that manner. RN/K felt that the incident represented patient maltreatment so she filled out a Maltreatment Report and placed it in the Director's office (on a Friday evening) and faxed it to the State agency. RN/K did not consider that the maltreatment issue needed to be followed up immediately to protect patient safety. RN/K did not consider removing HST/M from patient contact because RN/F was the Charge nurse and was aware of the incident.
LPN/L was interviewed on 05/12/15 at 11:40 a.m. and stated she held the door open between the units while HST/M and P4 came through the doorway on 05/08/15. LPN/L observed that P4 was sitting on the floor with his arms straight behind him and his legs straight out in front of him when P4 and HST/M passed through the doorway. HST/M was hanging onto P4 but LPN/L did not notice where HST/M had a hold of P4. LPN/L had never seen staff escort a patient by pulling on the patient while the patient was sitting on the floor. LPN/L reported and discussed this observation with RN/F who was the Charge nurse that shift.

HST/M was interviewed on 05/15/15 at 9:15 a.m. and stated P4 darted through the doors of 1-Down South that adjoins 1-Down North when a staff person opened them. P4 then sat on the floor on 1-Down North and refused to comply with returning to 1-Down South. HST/M stated he performed a "modified escort" for P4's safety. HST/M stated this modified escort was not taught in EASE training. HST/M just thought of it at the moment and doesn't know why he did it.

EASE Skills, Assess and Plan dated April 7, 2015 outlined authorized physical safety strategies used with imminent risk of harm in an emergency situation that is used to control or restrict the movements of a client. They include verbal and non-verbal communication, balanced stance, positioning, movement, blocks, wrist releases, bite releases, front hair pull, hair pulls from behind, choke or shirt grasp from behind, front choke or shirt grasp, show of support, escort strategy one, escort strategy two, escort strategy three, arms crossed in front of person escort, securing a person in place, and group/team strategies for wrap and containment.

Effective and Safe Engagement (EASE) Module 4: Group Safety Strategies, not dated, indicated its purpose is to promote physical and emotional safety for all by developing a plan that fits the circumstances, practicing your plan, put your plan in action when the situation requires it, and to talk with your team about the results; what worked, what did not, what did you learn, and adjust the plan as needed.

P1's hospital record was reviewed. P1's psychiatric assessment, dated 11/05/14, indicated that P1 was admitted for acute psychiatric care following discharge from an acute care hospital where P1 had undergone endoscopic procedures to remove foreign bodies from her intestines. P1 had a lengthy history of failed community placements in a variety of settings, due to P1's long history of ingestion of inanimate objects, necessitating frequent hospitalizations for foreign body removal. P1's primary diagnosis was Pica. P1's inpatient psychiatric treatment plan would be focused on sterilizing the environment to prevent further ingestion of objects. P1 would be placed on distant 1:1 monitoring to better manage P1's destructive impulses. All treatment programs would be on P1's unit. All personnel who came to P1's unit would divert themselves of any pens, objects, pins, earrings, or other small objects that could represent potential items of ingestion.

P1's incident reports from 11/3/14 to 2/17/15 were reviewed. P1 was sent to a hospital emergency room 6 times to remove foreign object that were ingested. The incidents indicated they were part of a pattern, however the incident forms did not indicate there were actions taken to minimize future occurrences. The following incidents demonstrated self-harm and/or suicide attempts that resulted in serious injury/illness:
o 11/3/14 at 6:45 p.m. P1 found, broke, and ingested parts of a pencil. P1 was taken to a hospital emergency room where an x-ray of the upper gastrointestinal tract found an ink pen, two batteries, but did not reveal pencil parts. P1 was sent back to the hospital to be monitored and wait for the items to pass through her gastrointestinal tract.
o 11/5/14 at 10:50 p.m. P1 told staff she an ingested a foreign object, a phone battery. P1 was taken to a hospital emergency room. P1 was hospitalized to monitor the gastrointestinal tract for the swallowed items that should pass with a bowel movement.
o 11/7/14 at 11:00 p.m. P1 told staff she ingested a foreign object, an ink pen cartridge, and a spring from a pen. P1 was taken to a hospital emergency room where the consumed items were removed endoscopically.
o 11/9/14 at 7:20 p.m., P1 told staff she ingested a foreign object, a pencil. P1 was taken to a hospital emergency room where an x-ray found a pen in the lower esophageal area, an ink pen spring in her lower colon and no evidence of a pencil. The consumed pen was removed endoscopically.
o 11/18/14 at 6:00 p.m. P1 ingested a marker that was stuck in P1's throat. P1 was taken to a hospital emergency room where the consumed marker was removed endoscopically.
o 1/20/15 at 5:30 a.m., P1 punctured right upper forearm (unknown object) and wrapped a sweatshirt around her neck three times causing her face to turn blue.
o 1/25/15 at 11:45 p.m. P1 tied an object around her neck, her face was pink, and blue mottled.
o 1/26/15 at 7:50 p.m., P1 entered the nursing office, took an item from the wall obtaining a screw, nail, and metal hook, and then ingested those items. P1 also broke a compact disc into pieces and told staff she swallowed approximately 30 or more pieces, as well as a pen she obtained from the nursing office. P1 did complain of abdominal, throat and chest pain, and difficulty breathing.
o 2/17/15 at 7:30 a.m. P1 told staff, she inserted a metal spring in her stomach a few days ago and could not take it out because it was stuck. Staff viewed the metal object in her abdomen; the area of the puncture was red with drainage. P1 was sent to a hospital emergency room and was admitted to the intensive care unit for septic shock.
The incident reports identified P1 ingested ingested the following items while at the hospital: pencils, pens, batteries, plastic parts, screws, compact disc, light bulb glass, hypodermic needle, and metal objects. P1's incidents included: self-injurious behavior/deliberate self-harm 25 times, ingestion of a foreign object (or substance) 15 times.

RN Supervisor (RNS)/(B) was interviewed on 04/30/15 at 8:00 a.m. RNS/(B) stated that P1's behavior of self-harm was well-known to hospital staff from P1's previous inpatient admissions. Before P1 was admitted on 11/03/14, the hospital opened a closed unit called One-Up, to accommodate P1's needs for a highly structured setting. Prior to P1's arrival on 11/03/14, One-Up was sanitized by staff for of all items by that posed risks for potential ingestion by counter-sinking screws, making sure doors were locked for unauthorized rooms and locked cabinets that had supplies. P1 was the only patient on One-Up. The unit was staffed with 2 staff at all times to ensure P1 received 1:1 distant staffing which meant that P1 was to be in staff's sight 100% of the time.

RN Supervisor (RNS)/B was interviewed on 04/30/15 at 8:55 a.m. RNS/B stated that it was not determined how or where P1 obtained a pencil on 11/03/14 and ingested it. Pencils were one of the items removed from the One-Up environment because P1 was known to ingest them. Once a day, each morning at the start of the day-shift, nursing staff completed an environmental assessment of 24 items to ensure One-Up was a safe environment for P1. The written checklist included items such as ensuring doors were properly locked, no broken glass or sharp objects were in patient areas, ceiling tiles/vents/carpeting were intact, and hallways were clear of unnecessary items. The checklist did not include assessing the environment for any contraband items that posed specific danger to P1, such as pens, pins, earrings, badges, pencils, cell phones, pop cans, plastic med cups, or other small objects. RNS/B did not know if the One-Up environmental assessment was completed each time P1 obtained contraband items or ingested them or self-harmed in the One-Up environment, such as P1's ability to obtain and ingest a pencil within three hours of admission to One-Up.

There was no evidence that staff evaluated and reviewed the pattern of occurrences when P1 obtained contraband items that were supposed to be inaccessible to her in an environment that was designed to safeguard P1.

The history and physical in P1's hospital #2 record, dated 02/18/15, indicated that the metal spring P1 had inserted into her abdomen was removed in the emergency room. P1 then underwent a gastroscopy surgical procedure. The surgeon removed three pen cartridges from P1's stomach and a pencil from P1's duodenum. During surgical exploration of the abdominal wall, a piece of a hypodermic needle was found in the abdominal wall and a second piece of a hypodermic needle was found free-floating in P1's abdomen. P1 was "gravely ill." Due to P1's critical condition, P1 needed a a higher level of acute care than could be provided at the local hospital. On 02/18/15, P1 was transferred to another hospital 65 miles away, to meet P1's medical needs.

The history and physical from hospital #3 where P1 was transferred, dated 02/18/15, indicated that P1 had severe septic shock secondary to acute peritonitis with abdominal wall injury caused by a wire or a hypodermic needle. P1's condition of severe sepsis resulted in acute kidney injury which required hemodialysis. P1 also had acute hypoxic respiratory failure, hypervolemia, and aspiration pneumonia which required full ventilatory support. P1 remained hospitalized through 03/09/15.

RN/F was interviewed on 05/05/15 at 2:30 p.m. RN/F stated she knew P1 from admissions prior to 11/03/14. Before P1's admission on 11/03/14, staff were given education about unit modifications on One-Up to increase P1's safety. P1 was very manipulative and knowledgeable about how to access contraband. Two staff were always assigned on One-Up to afford 1:1 supervision of P1. RN/F was assigned to P1's care numerous times. P1 accessed contraband twice and ingested it, when P1 had two staff assigned to her including RN/F. RN/F did not know how or where P1 obtained the contraband.

RN/H was interviewed on 05/15/14. RN/H worked with P1 several times on One-Up. P1 obtained contraband items on One-Up, despite the environment being sanitized of inedible items that P1 preferred, such as pens. RN/H did not know how or where P1 obtained contraband, because P1's access was restricted to only certain rooms on One-Up and all of P1's programs were done on One-Up. P1 never left One-Up for any reason, other than to go to the emergency department after an incident of contraband ingestion. RN/H stated that contraband searches of the One-Up environment were not routinely done by staff, even after an incident when P1 had ingested contraband. RN/H thought some of P1's ingestion's were the result of staff letting their guard down and allowing P1 to be too close to an area where a restricted door was open, like the nurse's office.

RN/G was interviewed on on 05/15/15 at 11:55 a.m. RN/G stated she worked with P1 on One-Up many times. Although the goal was to decrease the possibility of P1's ingestion's by providing a safe environment, P1 was still able to locate contraband in the environment and ingest it. P1 had 1:1 staffing and was always within staff's sight. Despite this, P1 was able to locate pens, screws, and other inanimate objects that P1 ingested in the One-Up environment. RN/G did not know how P1 obtained the contraband.

RN/I was interviewed on 05/05/15 at 9:05 a.m. RN/I stated he seldom worked on One-Up with P1. RN/I was working during the shift when P1 ripped the fire panel off the wall and took a screw and nail from it. Although RN/I observed P1 remove the fire panel, RN/I did not observe P1 ingest the screw or nail but P1 told RN/I she ingested them. Sometime later that same shift, RN/I's co-worker told RN/I that P1 had broken 2 CDs and ingested pieces of it. No contraband search was done between the two incidents that shift. RN/I didn't think staff routinely conducted contraband searches. It's a nursing decision to initiate a contraband search to ensure environmental safety. RN/I stated he thought many of the nursing staff were afraid of P1, due to her size, body weight, and random incidents of physical aggression.

Psychiatrist/C was interviewed on 05/05/15 at 10:35 a.m. Psychiatrist/C stated that the priority for P1 was P1's safety in her environment. P1 was admitted to an environment sanitized of contraband items. P1's goal was to participate in behavior therapies to reduce the risk of P1 engaging in ingesting inedible items. P1 was restricted to three rooms on One-Up. P1's precautions and level of supervision were evaluated daily by a licensed psychiatrist. A specific Treatment Plan aimed at protecting P1 from self-injurious behavior was developed and implemented. Although Psychiatrist/C was aware that P1 had numerous incidents of inedible ingestion's, Psychiatrist/C did not specifically review each incident as it occurred. As a result, timely modifications to the Master Treatment Plan were not initiated regarding P1's repeated incidents of ingestion of inedible items. Psychiatrist/C stated that P1 was very good at creating diversions so she could blow by staff and get into a restricted area to obtain an ingestible.

The hospital policy titled Safety and Infection Control Contraband and Program Safety dated 4/7/15, Effective 5/5/15, Policy Number 8100, indicated the purpose of the policy is to provide a safe and therapeutic treatment enviroment. Facilities must prohibit the introduction and possession of contraband, have trained staff to identify contraband and conduct searches. Staff is responsible for reporting the presence or suspected presence of contraband, collecting it and securing items in an appropriate location.

The hospital's document titled Critical Contraband List dated 1/19/15 indicated all items on the list are considered contraband. They include: chemical items, any items containing glass or mirrors, flammable items, laser pointers, media pornographic or violent materials, metal objects such as tools, loose metal or junk pieces, steel toe shoes/boots, utensils, razors/blades, wire, staples, pins, needles, paperclips, chains, ring binders, spiral notebooks, cans, scissors, tweezers, nail files, clippers, hair pins, hair accessories with metal, bobby pins, piercing supplies, and earrings, etc., weapons, long narrow items such as hair ties, scarves, neck ties, belts, clothing with cords, strings, and rope, clothing depicting alcohol/drugs/sex, if not approved by treatments team any electronic devices e.g. radios with cords, ipods, cell phones, and CD's, etc.

The hospital policy titled Client Care Therapeutic Precautions dated May 26, 2013, Procedure #13322, indicated a distant one-to one observations is when a staff member assigned shall keep the patient with in range of view at all times; frequent observations is when a staff member assigned shall observe the patient at least every 15 minutes during waking and sleeping hours and verbal interaction should occur during waking hours.