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Based on review of documents, medical records, video and staff interviews it was revealed the facility failed to ensure care was rendered in a safe setting, failed to ensure restraints were not used for retaliation, failed to ensure less restrictive interventions were used, failed to ensure the restraint was discontinued at the earliest possible time, failed to ensure documentation warranted the use of restraints and failed to ensure nursing could identify specific behavioral changes indicating the restraint was no longer necessary.

Based on staff interview, document review and review of patient #1's medical record it was revealed the nursing staff failed to provide care in a safe setting. This failure was identified in one (1) of thirty (30) medical records reviewed (patient #1). This failure has the potential to adversely affect all patients.

Findings include:

1. A review of the restraint episode documentation for 5/16/19 revealed that patient #1 was grabbed by his arms and pulled off the shelf/closet beside his bed. Patient #1 landed on his bed when he was pulled from the shelf.

2. An interview was conducted with the Assistant Director of Nursing (ADON) on 5/29/19 at 9:30 a.m. She stated Behavioral Health Technician (BHT) #4 said Registered Nurse (RN) #1 grabbed the patient inappropriately when patient was on the shelf in his room. She stated she spoke to RN #1 and patient #1 came off the shelving and fell on RN #1 on the bed. She stated she was informed RN #1 grabbed the patient's arm when trying to get him off the shelf. She stated patient #1 is a stout boy.

3. An interview was conducted with RN #1 on 5/29/19 at 10:31 a.m. She stated when she entered his room patient #1 was crouched on the shelf. She stated she grabbed him by his arms and pulled him off the shelf. She stated he crashed to the bed and that she was standing on the bed when she pulled him off the shelf. She stated she told him to get off the shelf twice before grabbing him and pulling him off.

4. An interview was conducted with BHT #3 on 5/29/19 at 3:35 p.m. She stated RN #1 escorted patient #1 to his room by herself. She stated RN #1 was screaming in there so she went to the door. She stated she saw patient #1 throwing cloths and swinging them. She said RN #1 pushed the patient on the bed and was pushing his hands and legs on the bed. She stated he ran out of the room and punched her on the shoulder. She stated she told him to stop but he was upset and he came to punch her again so she grabbed his hands. RN #1 and BHT #4 came and he ran to his room. She stated she looked into his room and BHT #4 looked upset.

5. A telephone interview was conducted with BHT #4 on 5/30/19 at 9:05 a.m. She stated she was working on Side A when the Licensed Practical Nurse (LPN) was screaming for help. She stated the patient ran into his room and climbed onto his shelf. RN #1 took his arm and jerked so hard he came down head first. She stated RN #1 did not ask the patient to get down before jerking him down.

6. An interview was conducted with the Director of Nursing (DON) on 5/30/19 at 1:45 p.m. She stated their investigation revealed RN #1 pulled patient #1 off the shelf in his room due to her fear that he would fall and get hurt. She stated it was noted RN #1 fell with the patient on his bed when he was pulled from the shelf. She concurred this was not the best way to get the patient off the shelf.

Based on document review and staff interview it was revealed the facility failed to ensure all patients had the right to be free from restraints imposed as a means of coercion, convenience or retaliation by staff. The facility failed to ensure restraints were used to ensure the immediate physical safety of the patient, a staff member or others and was discontinued at the earliest possible time. This failure was identified in one (1) of five (5) restraint or seclusion episodes reviewed (patient #1). This failure has the potential to adversely affect all patients.

Findings include:

1. A review of the video for 5/16/19 from 5:27 p.m. to 5:47 p.m. was conducted on 5/28/19 at 12:45 p.m. The video revealed at 5:32 p.m. patient #1 was escorted to his room by Registered Nurse (RN) #1. At 5:32:46 Behavioral Health Technician (BHT) #3 walked to his room door. At 5:33 p.m. patient #1 runs out of his room and was slamming doors on the unit. At 5:34:22 p.m. patient #1 is in his room and RN #1 and BHT #4 are in his room. At 5:34:37 BHT #3 is at patient #1's door. At 5:34:44 p.m. patient #1 was taken to the seclusion room by RN #1 and BHT #4. At 5:35:19 p.m. patient #1 was in a sitting restraint. At 5:35:50 p.m. patient #1 was kicking at RN #1 trying to hold his legs. At 5:36:13 p.m. patient #1 was in a supine restraint, BHT #4 was holding his arms and RN #1 was holding his legs. At 5:37:49 p.m. the Nurse Supervisor was assisting with the supine restraint. At 5:38 p.m. BHT #1 was in the seclusion room and was assisting with the supine restraint and RN #1 left the seclusion room. At 5:39:29 p.m. security was in the seclusion room and at 5:40 p.m. he was assisting with the supine restraint. At 5:43:04 BHT #2 was at the seclusion room door. At 5:43:15 BHT #2 leaves the seclusion room. At 5:44:47 p.m. no noticeable struggling noted from patient #1. At 5:45 p.m. BHT #1, BHT #4 and security had patient #1 in a supine restraint. The Nurse Supervisor had left the seclusion room. At 5:46:16 p.m. BHT #1 let go of patient #1's right arm. Patient #1 raised his right shoulder and security touched his right shoulder. After security had removed his hand from the patient's right shoulder, patient #1 laid back on the floor and BHT #1 grasped his right arm again. No struggling was noted at this time. At 5:46:19 p.m. RN #1 returned to the seclusion room. At 5:46:32 patient #1 stands up from the supine restraint without struggling and is lead to the restraint room by BHT #1 and BHT #4. Patient #1 is walking backwards while being taken to the restraint room. At 5:47:01 p.m. patient #1 entered the restraint room and no struggling was noted on the video at this time

2. A review of the restraint and seclusion flow sheet for 5/16/19 revealed patient #1 was placed in four (4) point restraints at 5:35 p.m. Restraints were removed at 6:23 p.m.

3. An interview was conducted with BHT #1 on 5/29/19 at 10:21 a.m. He stated he was called due to patient #1 being out of control. He stated when patient #1 was in the supine restraint and they were talking to him he felt him calm down. He stated when RN #1 said to restrain patient #1 he told her patient #1 had committed to safety. RN #1 said the restraints are ready and to take him to the restraints. He stated patient #1 was struggling to get up when RN #1 came in the room. He stated the patient told BHT #4 he was calm. When asked if he was struggling when getting patient #1 up to escort to four (4) point restraints he said he did not struggle or threaten anyone when getting up. He stated he did not curse and had calmed down. He felt patient #1 committed to safety so he would not be in four (4) point restraints. He stated he did not struggle walking to the restraint room. Patient #1 laid down on the bed willingly and did not struggle or curse. He stated the patient did not say anything when restrained.

4. An interview was conducted with RN #1 on 5/29/19 at 10:31 a.m. She stated BHT #2 put restraints on the bed and asked if he could take the patient to restraints. She stated she was sitting at the nurse's station when BHT #2 asked about the restraints. She stated she told the BHT yes due to patient #1 still struggling. RN #1 denied returning to the seclusion room once she left to do the calls. She stated, "Once in the room, I did not help put him in restraints." She stated restraints doesn't bother him as he is a manipulative tough boy. She stated he will tell you how to put them on. She stated he doesn't get along with other kids.

5. An interview was conducted with BHT #2 on 5/29/19 at 3:10 p.m. He stated he was on break when patient #1 was in a hold and supine restraint. He stated when he returned he went to RN #1 asked what to do and he was told to put restraints on the bed. After the restraints were put on the bed patient #1 had completely calmed down. He was conversing appropriately and felt he could have been let up. He stated he told RN #1 that patient #1 was completely calm and RN #1 said very vindictively, "It did not matter he was going to restraints." He stated everyone else agreed with him that patient #1 should not be put in restraints. He stated patient #1 was so calm. He was asking questions why he was going to be restrained as he had done everything he was supposed to do. He was cooperative. He stated patient #1 laid on the restraint bed and he tried to be very comforting to the patient. He stated security wrote a statement and he was very mad the patient was restrained. He stated everyone felt patient #1 should not have been in restraints. He stated when RN #1 told him to tell them to restrain him, he stated, "I told her I wasn't going to tell them he needed to go into restraints. I totally disagreed with it." Everyone voiced he did not need to go into restraints and said he was calm, cooperative and should be let go. He stated I think she told someone she was not letting him out early. He stated he felt her facial expression showed it was a punishment. He stated the patient shouldn't have been there.

6. An interview was conducted with security on 5/29/19 at 3:23 p.m. He stated BHT #1 and BHT #4 established a rapport with the patient. The patient said it was really stupid what he was doing. He stated patient #1 had good realization and at that point he thought they would start releasing him. The patient had committed to safety and he knew what to do. At that point he had started to release his legs but his arms were still around his legs in case something happened. He stated the patient knew what was going on and committed to safety a second time. He stated everyone told the RN the patient committed to safety, but she said there were straps on the bed and that's where she wanted him. When he helped him up he was calm, but the nurse stated she wanted him in the seclusion room. He stated the patient was really confused. BHTs calmed him and reassured him he would not be there long. He stated he didn't feel threatened as he wasn't in that mood. He stated the patient laid on the restraint bed and repositioned his arm to be strapped down. He stated, "Shouldn't have happened."

7. An interview was conducted with BHT #3 on 5/29/19 at 3:35 p.m. She stated she asked the RN what she wanted her to do and RN #1 said to put restraints on the bed. She stated when she went to tell them it was ready patient #1 had calmed and was just laying there. He was just talking. She stated she told the RN he was calm but she still wanted him restrained. She stated he asked why he was being restrained. They asked the patient if he was going to struggle when he walked to the restraint room but he did not fight them at all. She stated he was calm in the restraint room. She stated she monitored him and RN #2 did the face to face and said he was calm. RN #2 returned to the restraint room and asked how long the patient been there and she told her almost an hour. RN #2 said he can only be there an hour. She stated she told RN #2 she had been waiting for RN #1 to release him. She stated when RN #1 came to the restraint room she said harshly to her it was her fault the patient wasn't released. She stated she told RN #1 she had to have an RN to release the patient. She stated RN #1 let the patient up while telling her it was her fault. She stated she felt patient #1 should have been held longer but doesn't feel he should have been in restraints at that time. She stated she did not express concerns but knew it wasn't right.

8. A telephone interview was conducted with BHT #4 on 5/30/19 at 9:05 a.m. She stated when BHT #2 came in the room and said restraints are ready he was told patient #1 was calm. BHT #2 went back and told RN #1 he was calm. RN #1 came in anyway and said restraints on the bed. She stated BHT #1, security and herself said he was calm and should not be in restraints. RN #1 said to go ahead and take him. She stated he was a two (2) person escort to the restraint room. He walked to the restraint room and did not fight or anything. He started to put himself into restraints. She stated he was very calm, no cursing. She stated, "I was very upset, there was no point to put him there." She stated he asked why he was being put in restraints.

9. An interview was conducted with the Director of Nursing (DON) on 5/30/19 at 1:45 p.m. She stated she agreed the restraint log is lacking documentation for the need of restraints. She stated it is her expectation that the BHT would call out that the patient is calm while in restraints to get the RN's attention to remove restraints. She stated she was unaware of the issues regarding patient #1 being put in four (4) point restraints on 5/16/19. She stated the Program Manager of the Children's Unit watched the video for the restraint episode on 5/16/19, interviewed staff, reviewed statements and felt the restraint episode was justified.

10. An interview was conducted with the Director of Quality on 5/30/19 at 2:45 p.m. She stated the DON is removing RN #1 from patient care.

Based on record review, staff interview and document review it was determined the facility failed to use the least restrictive restraint intervention for one (1) out of five (5) restrained patients (patient #1). This failure has the potential to negatively impact all restrained patients.

Findings include:

1. A review was conducted of patient #1's medical record. The patient had aggressive behaviors on 05/16/19 including elbowed another patient and then hit staff and climbed on top of shelf which resulted in a restraint episode. The restraint episode was initiated at 5:25 p.m. with a seated restraint, then a four (4) point restraint at 5:35 p.m. and discontinued at 6:23 p.m. The last documentation of patient struggling was at 5:35 p.m. The documentation stated the patient was conversing appropriately and lying down starting at 5:51 p.m. and every five (5) minutes until restraints were removed at 6:23 p.m.

2. An interview with Behavior Health Technician (BHT) #1 was conducted on 5/29/19 at 10:20 a.m. He stated in part, "Prior to taking patient #1 into restraint room to initiate four (4) point restraints he said he committed to safety. I told the Registered Nurse (RN) #1 that he had committed to safety. The RN said restraints are prepared, take him to the restraints. He did not struggle or threaten when we got patient up to take into the restraint room."

3. An interview was conducted with BHT #2 on 05/29/19 at 3:09 p.m. He stated in part, "Patient #1 was conversing appropriately. I felt like he could have been let up. I told her (RN #1) that. She said it didn't matter, he was going in restraints. As I followed them into the restraint room, he (patient #1) was asking why he was being put in restraints. I tried to comfort him and told him we would get him out as soon as possible. Everyone felt patient #1 didn't need to be in restraints, he was calm and cooperative."

4. An interview was conducted with Security on 5/29/19 at 3:22 p.m. He stated in part, "The patient was calm and in realization with what he was doing. We asked the patient if he committed to safety, he said he did and would go to his room. I had let up on his legs and the patient was relaxed and flaccid. We asked a second time if patient commits to safety, he said he did. The RN came in the time away room and stated, "the restraints are on the bed, that's where I want him." The patient seemed confused and the BHTs reassured him he wouldn't be in restraints long. I did not feel threatened his legs were loose as we escorted him into the restraint room. The patient crawled up onto the restraint bed and repositioned his own arms so the restraints could be placed."

5. A telephone interview was conducted with BHT #4 on 5/30/19 at 9:03 a.m. She stated in part, "During the supine restraint hold in the time away room RN came into the room and said restraints are on the bed. All three of us said he was calm. RN said take him anyway. He walked to the restraint room, he did not fight. He started to put himself in the restraint. He was very calm, wasn't cursing. I was upset, he didn't need to be in restraints."

6. An interview with BHT #3 was conducted on 05/29/19 at 3:34 p.m. She stated in part, "I helped get restraints onto the bed. I told the other staff the restraints were ready. They said he was calm and committed to safety. We told RN he was calm. She said she still wanted him in restraints. The patient walked to the restraint room with only a two (2) person escort and didn't struggle in any way. After the patient (patient #1) was placed in four (4) point restraints he remained calm. I didn't think right at that time that he needed restraints." The RN who ordered the restraints came into the room at 6:21 p.m. for the first time and harshly stated it was my fault that the patient wasn't released. I explained I had to have an RN tell me to release the restraints. RN released the patient all at once."

7. An interview with the Director of Nursing (DON) was conducted on 5/30/19 at 1:45 p.m. She stated, "The documentation is lacking regarding the use of restraints." She confirmed there was no additional restraint documentation.

8. A review was conducted of policy Seclusion and Restraint, last revised 09/2018. Under section POLICY it is stated: "The least restrictive method of seclusion/restraint will be utilized."

Based on record review, staff interview and document review it was determined the facility failed to ensure restraints were discontinued at the earliest possible time for one (1) out of five (5) restrained patients, (patient #1). This failure has the potential to negatively impact all restrained patients.


Findings include:

1. A review was conducted of patient #1's medical record. The patient had aggressive behaviors on 05/16/19 including elbowed another patient and then hit staff and climbed on top of shelf which resulted in a restraint episode. The restraint episode was initiated at 5:25 p.m. with a seated restraint, then a four (4) point restraint at 5:35 p.m. and discontinued at 6:23 p.m. The last documentation of patient struggling was at 5:35 p.m. The documentation stated the patient was conversing appropriately and lying down starting at 5:51 p.m. and every five (5) minutes until restraints were removed at 6:23 p.m.

2. An interview with Behavior Health Technician (BHT) #1 was conducted on 5/29/19 at 10:20 a.m. He stated in part, "Prior to taking patient #1 into restraint room to initiate four (4) point restraints he said he committed to safety. I told the Registered Nurse (RN) #1 that he had committed to safety. The RN said restraints are prepared, take him to the restraints. He did not struggle or threaten when we got patient up to take into the restraint room."

3. An interview was conducted with BHT #2 on 05/29/19 at 3:09 p.m. He stated in part, "Patient #1 was conversing appropriately. I felt like he could have been let up. I told her (RN #1) that. She said it didn't matter, he was going in restraints. As I followed them into the restraint room, he (patient #1) was asking why he was being put in restraints. I tried to comfort him and told him we would get him out as soon as possible. Everyone felt patient #1 didn't need to be in restraints, he was calm and cooperative."

4. An interview was conducted with Security on 5/29/19 at 3:22 p.m. He stated in part, "The patient was calm and in realization with what he was doing. We asked the patient if he committed to safety, he said he did and would go to his room. I had let up on his legs and the patient was relaxed and flaccid. We asked a second time if patient commits to safety, he said he did. The RN came in the time away room and stated, "the restraints are on the bed, that's where I want him." The patient seemed confused and the BHTs reassured him he wouldn't be in restraints long. I did not feel threatened his legs were loose as we escorted him into the restraint room. The patient crawled up onto the restraint bed and repositioned his own arms so the restraints could be placed."

5. A telephone interview was conducted with BHT #4 on 5/30/19 at 9:03 a.m. She stated in part, "During the supine restraint hold in the time away room RN came into the room and said restraints are on the bed. All three of us said he was calm. RN said take him anyway. He walked to the restraint room, he did not fight. He started to put himself in the restraint. He was very calm, wasn't cursing. I was upset, he didn't need to be in restraints."

6. An interview with BHT #3 was conducted on 05/29/19 at 3:34 p.m. She stated in part, "I helped get restraints onto the bed. I told the other staff the restraints were ready. They said he was calm and committed to safety. We told RN he was calm. She said she still wanted him in restraints. The patient walked to the restraint room with only a two (2) person escort and didn't struggle in anyway. After the patient (patient #1) was placed in four (4) point restraints he remained calm. I didn't think right at that time that he needed restraints." The RN who ordered the restraints came into the room at 6:21 p.m. for the first time and harshly stated it was my fault that the patient wasn't released. I explained I had to have an RN tell me to release the restraints. RN released the patient all at once."

7. An interview with the Director of Nursing (DON) was conducted on 5/30/19 at 1:45 p.m. Regarding the restraint documentation she stated, "I would expect the BHT to call out the patient is calm to get the RN's attention to remove the restraints."

8. A review was conducted of policy Seclusion and Restraint, last revised 09/2018. Section Documentation in Restraint/Seclusion/Safety Packet, Number Three (3) states: "Explanation of Release Criteria to Patient: Commit to safety, cessation of verbal threats and violent behaviors."

Based on document review and staff interview it was revealed the facility failed to ensure to employ appropriate intervention for the identified behavior. This failure was identified in one (1) of five (5) restraint/seclusion episodes reviewed for patient #1. This failure has the potential to adversely affect all patients.

Findings include:

1. An interview was conducted with BHT #1 on 5/29/19 at 10:21 a.m. He stated when patient #1 was in the supine restraint and they were talking to him he felt him calm down. He stated the patient told BHT #4 he was calm. When asked if he was struggling when getting patient #1 up to escort to four (4) point restraints, he said he did not struggle or threaten anyone. He stated he did not curse, he had calmed down. He felt patient #1 committed to safety so he would not be in restraints. He stated he did not struggle walking to the restraint room. Patient #1 laid down on the bed willingly and did not struggle or curse. He stated the patient did not say anything when restrained.

2. An interview was conducted with BHT #2 on 5/29/19 at 3:10 p.m. He stated after the restraints were put on the bed patient #1 had completely calmed down. He was conversing appropriately and he felt he could have been let up. He stated he told RN #1 that patient #1 was completely calm and RN #1 said very vindictively that it did not matter, he was going to restraints. He stated everyone else agreed with him that patient #1 should not be put in restraints. He stated patient #1 was so calm. He was asking questions why he was going to be restrained as he had done everything he was supposed to do. He was corporative. He stated patient #1 laid on the restraint bed and he tried to be very comforting to the patient. He stated security wrote a statement and he was very mad the patient was restrained. He stated everyone felt patient #1 should not have been in restraints. He stated when RN #1 told him to tell them to restrain him he stated, "I told her I wasn't going to tell them he needed to go into restraints. I totally disagreed with it." Everyone voiced he did not need to go into restraints, said he was calm, corporative and should be let go. He stated I think she told someone she was not letting him out early. He stated he felt her facial expression showed it was a punishment. He stated the patient shouldn't have been there.

3. An interview was conducted with security on 5/29/29 at 3:23 p.m. He stated the patient said it was really stupid what he was doing. He stated patient #1 had good realization at that point and he thought they would start releasing him. Patient #1 had committed to safety and knew what to do. At that point he had started to release his legs but his arms were still around his legs in case something happened. He stated the patient knew what was going on and he committed to safety a second time. He stated everyone told the RN the patient committed to safety. RN #1 stated straps are on the bed and that is where she wants him. When he helped him up he was calm, but the nurse stated she wanted him in the seclusion room. He stated the patient was really confused. BHTs calmed him and reassured him he would not be there long. He stated he didn't feel threatened as he wasn't in that mood. He stated the patient laid on the restraint bed and repositioned his arm to be strapped down. He stated, "Shouldn't have happened."

4. An interview was conducted with BHT #3 on 5/29/19 at 3:35 p.m. She stated she told the RN he was calm but she still wanted him restrained. She stated he asked why he was being restrained. They asked the patient if he was going to struggle when he walked to the restraint room but he did not fight them at all. She stated in the restraint room he was calm. She stated she monitored him and RN #2 did the face to face and said he was calm.

5. A telephone interview was conducted with BHT #4 on 5/30/19 at 9:05 a.m. She stated when BHT #2 came in the room and said restraints are ready, he was told patient #1 was calm. BHT #2 went back and told RN #1 he was calm. RN #1 came in anyway and said restraints on the bed. She stated BHT #1, security and herself said he was calm and should not be in restraints. RN #1 said to go ahead and take him. She stated he was a two (2) person escort to the restraint room. He walked to the restraint room and did not fight or anything. He started to put himself into restraints. She stated he was very calm, no cursing. She stated, "I was very upset, there was no point to put him there."

6. An interview was conducted with the DON on 5/30/19 at 1:45 p.m. She stated she agrees the restraint log is lacking documentation for the need of restraints. She stated she was unaware of the issues regarding patient #1 being put in four (4) point restraints on 5/16/19. She stated the Program Manager of the Children's Unit watched the video for the restraint episode on 5/16/19, interviewed staff, reviewed statements and felt the restraint episode was justified.

7. An interview was conducted with the Director of Quality on 5/30/19 at 2:45 p.m. She stated the DON is removing RN #1 from patient care.

Based on review of video, documents, medical record and staff interview it was revealed nursing staff failed to identify specific behavioral changes indicating the restraint was no longer necessary. This failure was identified in one (1) of five (5) restraint episodes reviewed (patient #1). This failure has the potential to adversely affect all patients.

Findings include:

1. An interview was conducted with BHT #1 on 5/29/19 at 10:21 a.m. He stated when patient #1 was in the supine restraint and they were talking to him he felt him calm down. He stated the patient told BHT #4 he was calm. When asked if he was struggling when getting patient #1 up to escort to four (4) point restraints, he said he did not struggle or threaten anyone. He stated he did not curse, he had calmed down. He felt patient #1 committed to safety so he would not be in restraints. He stated he did not struggle walking to the restraint room. Patient #1 laid down on the bed willingly and did not struggle or curse. He stated the patient did not say anything when restrained.

2. An interview was conducted with BHT #2 on 5/29/19 at 3:10 p.m. He stated after the restraints were put on the bed patient #1 had completely calmed down. He was conversing appropriately and he felt he could have been let up. He stated he told RN #1 that patient #1 was completely calm and RN #1 said very vindictively that it did not matter, he was going to restraints. He stated everyone else agreed with him that patient #1 should not be put in restraints. He stated patient #1 was so calm. He was asking questions why he was going to be restrained as he had done everything he was supposed to do. He was corporative. He stated patient #1 laid on the restraint bed and he tried to be very comforting to the patient. He stated security wrote a statement and was very mad the patient was restrained.. He stated everyone felt patient #1 should not have been in restraints. He stated when RN #1 told him to tell them to restrain him, he stated, "I told her I wasn't going to tell them he needed to go into restraints. I totally disagreed with it." Everyone voiced he did not need to go into restraints, said he was calm, corporative and should be let go. He stated I think she told someone she was not letting him out early. He stated he felt her facial expression showed it was a punishment. He stated the patient shouldn't have been there.

3. An interview was conducted with security on 5/29/29 at 3:23 p.m. He stated the patient said it was really stupid what he was doing. He stated patient #1 had good realization at that point and he thought they would start releasing him. Patient #1 had committed to safety and knew what to do. At that point he had started to release his legs but his arms were still around his legs in case something happened. He stated the patient knew what was going on and he committed to safety a second time. He stated everyone told the RN the patient committed to safety. RN #1 stated straps are on the bed and that is where she wants him. When he helped him up he was calm, but the nurse stated she wanted him in the seclusion room. He stated the patient was really confused. BHTs calmed him and reassured him he would not be there long. He stated he didn't feel threatened as he wasn't in that mood. He stated the patient laid on the restraint bed and repositioned his arm to be strapped down. He stated, "Shouldn't have happened."

4. An interview was conducted with BHT #3 on 5/29/19 at 3:35 p.m. She stated she told the RN he was calm but she still wanted him restrained. She stated he asked why he was being restrained. They asked the patient if he was going to struggle when he walked to the restraint room but he did not fight them at all. She stated in the restraint room he was calm. She stated she monitored him and RN #2 did the face to face and said he was calm.

5. A telephone interview was conducted with BHT #4 on 5/30/19 at 9:05 a.m. She stated when BHT #2 came in the room and said restraints are ready he was told patient #1 was calm. BHT #2 went back and told RN #1 he was calm. RN #1 came in anyway and said restraints on the bed. She stated BHT #1, security and herself said he was calm and should not be in restraints. RN #1 said to go ahead and take him. She stated he was a two (2) person escort to the restraint room. He walked to the restraint room and he did not fight or anything. He started to put himself into restraints. She stated he was very calm, no cursing. She stated, "I was very upset, there was no point to put him there."

6. An interview was conducted with the Director of Nursing (DON) on 5/30/19 at 1:45 p.m. She stated she agrees the restraint log is lacking documentation for the need of restraints. She stated she was unaware of the issues regarding patient #1 being put in four (4) point restraints on 5/16/19. She stated the Program Manager of the Children's Unit watched the video for the restraint episode on 5/16/19, interviewed staff, reviewed statements and felt the restraint episode was justified.

7. An interview was conducted with the Director of Quality on 5/30/19 at 2:45 p.m. She stated the DON is removing RN #1 from patient care.

Based on record review, staff interview and document review it was determined one (1) out of thirty (30) patients (patient #13) was discharged from the facility without a physician order. This failure has the potential to negatively impact all patient care.

Findings include:

1. A review was conducted of patient #13's medical record on 5/29/19. The patient was admitted to the facility on 05/22/19 and discharged 5/29/19. No physician order for discharge was in the patient's record.

2. An interview with the Electronic Medical Record (EMR) Specialist was conducted on 5/29/19 at 3:00 p.m. He confirmed there was no physician order.

3. A training document titled Discharge Process for Avatar was reviewed on 5/30/19. Number one (1) states: "Make sure there is a discharge home order in Avatar."

4. An interview was conducted with the Quality Assurance/Performance Improvement (QAPI) Director on 5/29/19 at 3:15 p.m. She concurred the patient was discharged without a physician order.

A. Based on document review, record review and staff interview it was determined the nursing staff failed to provide care in a safe setting. This failure was identified in one (1) of thirty (30) medical records reviewed (patient #1). This failure has the potential to adversely affect all patients.

Findings include:

1. A review of the restraint episode documentation for 5/16/19 revealed documentation that patient #1 was grabbed by his arms and pulled off the shelf/closet beside his bed. Patient #1 landed on his bed when he was pulled from the shelf.

2. An interview was conducted with the Assistant Director of Nursing (ADON) on 5/29/19 at 9:30 a.m. She stated BHT #4 said RN #1 grabbed the patient inappropriately when patient was on the shelf in his room. She stated she spoke to RN #1 and patient #1 came off the shelving and fell on RN #1 on the bed. She stated she was informed RN #1 grabbed the patient's arm when trying to get him off the shelf. She stated patient #1 is a stout boy.

3. An interview was conducted with RN #1 on 5/29/19 at 10:31 a.m. She stated when she entered his room patient #1 was crouched on the shelf. She stated she grabbed him by his arms and pulled him off the shelf. She stated he crashed to the bed and she was standing on the bed when she pulled him off the shelf. She stated she told him to get off the shelf twice before grabbing him and pulling him off the shelf.

4. An interview was conducted with BHT #3 on 5/29/19 at 3:35 p.m. She stated RN #1 escorted patient #1 to his room by herself. She stated RN #1 was screaming in there so she went to the door. She stated she saw patient #1 throwing cloths and swinging them. She said RN #1 pushed the patient on the bed and was pushing his hands and legs on the bed. She stated he ran out of the room and punched her on the shoulder. She stated she told him to stop but he was upset and came to punch her again so she grabbed his hands. RN #1 and BHT #4 came and he ran to his room. She stated she looked into his room and BHT #4 looked upset.

5. A telephone interview was conducted with BHT #4 on 5/3019 at 9:05 a.m. She stated she was working on Side A when the Licensed Practical Nurse (LPN) was screaming for help. She stated the patient ran into his room and climbed onto his shelf. RN #1 took his arm and jerked so hard he came down head first. She stated RN #1 did not ask the patient to get down before jerking him down.

6. An interview was conducted with the Director of Nursing (DON) on 5/30/19 at 1:45 p.m. She stated their investigation revealed RN #1 pulled patient #1 off the shelf in his room due to her fear he would fall and get hurt. She stated it was noted RN #1 fell with the patient on his bed when he was pulled from the shelf. She concurred this was not the best way to get the patient off the shelf.

B. Based on review of video, documents, medical record and staff interview it was determined nursing staff failed to identify specific behavioral changes indicating the restraint was no longer necessary. This failure was identified in one (1) of five (5) restraint episodes reviewed (patient #1). This failure has the potential to adversely affect all patients.

Findings include:

1. An interview was conducted with BHT #1 on 5/29/19 at 10:21 a.m. He stated when patient #1 was in the supine restraint and they were talking to him he felt him calm down. He stated the patient told BHT #4 he was calm. When asked if he was struggling when getting patient #1 up to escort to four (4) point restraints he said he did not struggle or threaten anyone. He stated he did not curse, he had calmed down. He felt patient #1 committed to safety so he would not be in restraints. He stated he did not struggle walking to the restraint room. Patient #1 laid down on the bed willingly and did not struggle or curse. He stated the patient did not say anything when restrained.

2. An interview was conducted with BHT #2 on 5/29/19 at 3:10 p.m. He stated after the restraints were put on the bed patient #1 had completely calmed down. He was conversing appropriately and he felt he could have been let up. He stated he told RN #1 that patient #1 was completely calm and RN #1 said very vindictively that it did not matter, he was going to restraints. He stated everyone else agreed with him that patient #1 should not be put in restraints. He stated patient #1 was so calm. He was asking questions why he was going to be restrained as he had done everything he was supposed to do. He was corporative. He stated patient #1 laid on the restraint bed and he tried to be very comforting to the patient. He stated security wrote a statement and was very mad the patient was restrained.. He stated everyone felt patient #1 should not have been in restraints. He stated when RN #1 told him to tell them to restrain him, he stated, "I told her I wasn't going to tell them he needed to go into restraints. I totally disagreed with it." Everyone voiced he did not need to go into restraints, said he was calm, corporative and should be let go. He stated I think she told someone she was not letting him out early. He stated he felt her facial expression showed it was a punishment. He stated the patient shouldn't have been there.

3. An interview was conducted with security on 5/29/29 at 3:23 p.m. He stated the patient said it was really stupid what he was doing. He stated patient #1 had good realization at that point and he thought they would start releasing him. Patient #1 had committed to safety and knew what to do. At that point he had started to release his legs but his arms were still around his legs in case something happened. He stated the patient knew what was going on and he committed to safety a second time. He stated everyone told the RN the patient committed to safety. RN #1 stated straps are on the bed and that is where she wants him. When he helped him up he was calm, but the nurse stated she wanted him in the seclusion room. He stated the patient was really confused. BHTs calmed him and reassured him he would not be there long. He stated he didn't feel threatened as he wasn't in that mood. He stated the patient laid on the restraint bed and repositioned his arm to be strapped down. He stated, "Shouldn't have happened."

4. An interview was conducted with BHT #3 on 5/29/19 at 3:35 p.m. She stated she told the RN he was calm but she still wanted him restrained. She stated he asked why he was being restrained. They asked the patient if he was going to struggle when he walked to the restraint room but he did not fight them at all. She stated in the restraint room he was calm. She stated she monitored him and RN #2 did the face to face and said he was calm.

5. A telephone interview was conducted with BHT #4 on 5/30/19 at 9:05 a.m. She stated when BHT #2 came in the room and said restraints are ready he was told patient #1 was calm. BHT #2 went back and told RN #1 he was calm. RN #1 came in anyway and said restraints on the bed. She stated BHT #1, security and herself said he was calm and should not be in restraints. RN #1 said to go ahead and take him. She stated he was a two (2) person escort to the restraint room. He walked to the restraint room and he did not fight or anything. He started to put himself into restraints. She stated he was very calm, no cursing. She stated, "I was very upset, there was no point to put him there."

6. An interview was conducted with the Director of Nursing (DON) on 5/30/19 at 1:45 p.m. She stated she agrees the restraint log is lacking documentation for the need of restraints. She stated she was unaware of the issues regarding patient #1 being put in four (4) point restraints on 5/16/19. She stated the Program Manager of the Children's Unit watched the video for the restraint episode on 5/16/19, interviewed staff, reviewed statements and felt the restraint episode was justified.

7. An interview was conducted with the Director of Quality on 5/30/19 at 2:45 p.m. She stated the DON is removing RN #1 from patient care.