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Based on record review and interview, the hospital governing body failed to ensure that one of 13 patients (Patient #23) was supervised and cared for by hospital personnel trained in safely handling emergency patient behavior (Crisis Prevention Intervention, CPI) and allowed a staff member (Personnel J) to lapse the required training between 04/08/23 and 06/30/23. Patient #23 was hospital admitted with a history of multiple psychiatric hospitalizations and diagnoses that included Schizoaffective Disorder. The patient required being restrained from physically attacking others on at least three occasions before she severely injured a staff member on 06/11/23. Not being trained in safe patient emergency management, Personnel J grabbed the patient after the incident and dragged her into the quiet room. Personnel J remained in active milieu management for at least two more weeks.


Findings included:

Patient #23 was involuntarily hospital admitted on 06/05/23 at 1612 and discharged on 06/13/23 at 1307 according to the patient's Demographic Profile document.

Record review of Patient #23's Psychiatric Evaluation dated 06/06/23 at 0900 reflected the patient had a history of "20 + inpatient hospitalizations." The patient was unkempt, irritable, with poor insight and judgement, and on observation level for suicidal, aggressive, and sexual acting out behavior. The patient's diagnoses included Schizoaffective Disorder; she was expected to require seven to 10 days of hospitalization.

Risk Restraint or Seclusion documents dated 06/09/23 at 0503, 06/10/23 at 0511, and 06/11/23 at 0740 reflected the patient's physical aggression toward self, staff, and/or others.

Nursing Progress Notes dated 06/11/23 at 0729 reflected the patient was "aggressive ...abusive ...combative ...hit staff on her right eye ...site bruised ...swollen ..."

Personnel D stated during an interview on 07/06 at 1545 that Patient #23 hit Personnel I in the eye on 06/11/23 at 0729.

On 07/06/23 at 1600, Personnel D reviewed the video surveillance tape of the 06/11/23 incident involving Patient #23 and stated that the way Personnel J managed the patient's emergency behavior " ...was not CPI technique ....tried to pull the patient up and grabbed her breasts ...dragged her ..."

Personnel B was interviewed on 07/06/23 at 1250 and stated that Personnel J was hired on 03/27/23 and "did not comply with training requirements...did not attend CPI .... suspended on 06/30/23."

The staffing schedule dated 06/24/23 (night shift) was hospital administratively provided and received on 07/06/23 at 1430. It reflected Personnel J was the only mental health technician on the PICU unit to begin the shift at 2200 and was assigned to manage the behavior of twelve patients.

During an interview on 07/05/23 at 1430, Personnel E reviewed the staffing schedule and agreed with the above findings.