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Based on interview, record review, and policy review, the facility failed to:
- Immediately remove staff from duty after allegations of potential abuse were voiced to the facility administrator on call (House Supervisor). (Refer to A-0144)
- Prevent staff to patient abuse of one current patient (#4) of one current patient reviewed for potential staff to patient abuse. (Refer to A-0145)
- Initiate an investigation when allegations of staff to patient abuse (Patient #4) were reported. (Refer to
A-0145)

These failures created an unsafe environment and had the potential to place all patients admitted to the facility at risk for their safety. The facility census was 955.

The severity and cumulative effect of these systemic practices resulted in the overall non-compliance with 42 CFR 482.13 Condition of Participation: Patient's Rights that resulted in a condition of Immediate Jeopardy (IJ).

As of 10/27/17, at the time of the survey exit, the facility provided an immediate action plan sufficient to remove the IJ when the facility implemented the following actions:
- Immediate education on abuse for all hospital staff to include:
- Types and forms of abuse;
- How to recognize abuse; and
- What to do if abuse is witnessed.
- Mangers to communicate refresher education points to current staff working; and to educate oncoming evening and night shift staff prior to starting their shifts.
- Security staff will be educated by the Manager and/or Director of Patient Safety & Quality.
- Education to continue so that all staff are educated and staff on FMLA (Family Medical Leave of Absence) or on Time Off to be educated prior to the start of the first shift upon return.
- Education to all resident and attending physician staff addressing that upon suspicion or concern of abuse, the reporting process occurs immediately.
- Abuse Investigation: Initiated abuse investigation on 10/26/17 for alleged abuse event occurring on 10/15/17. Following interview of the security officer, he was placed on administrative leave pending the outcome of the investigation.
- Immediate suspension of all pain point maneuvers; communicated on 10/27/17 to Public Safety Staff by Director.
- All security, nursing and sitter staff involved in the event will receive individual counseling on appropriate response to abuse concerns before their next working shift.
- Beginning October 27, 2017, abuse-related scenario will be presented to current staff working daily per shift for two weeks, then if at 100%, daily on alternating shifts until the re-visit for all hospital staff including physician and resident staff.
- Education on Abuse and Neglect upon hire and annually: Education addressing types and forms of abuse; how to recognize abuse; what to do if abuse is witnessed and how to report is currently performed at the time of new employee orientation and for agency staff prior to working first shift. Patient abuse scenarios will be added to this training to ensure comprehension starting with November orientation sessions and agency staff beginning November shifts.
- Informed Consent process for patients with guardians:
- Refresher education for RN's, Social Workers, Residents, and Attending Physicians on identifying and communicating guardian status, and to ensure that guardians are accessed to provide consent when required.
- A sticker will be placed on chart spines and at the head of the bed to indicate patient has a guardian.
- Daily case management staff will ensure sticker and above bed sign for patients with legal guardians and report compliance to Director of Case Management with follow up as needed.
- Continuing Education on Patients with Legal Guardians: Beginning October 27,2017, a legal guardian scenario will be presented to current staff working daily per shift for two weeks, then if at 100%, daily on alternating shifts until the re-visit.



18018

Based on interview, record review and policy review, the facility failed to seek the written consent of the patient's representative (legal guardian, a person who has the legal authority to care for the personal and property interests of another person, called a ward) for one current patient (#4) of one current patient reviewed with a patient representative for consents when informed consent was required for a care decision. This failure had the potential to affect all patients admitted to the facility with patient representatives to be allowed to give informed consent for care decisions. The facility census was 955.

Findings included:

1. Record review of the facility policy titled, "Informed Consent for Medical and Surgical Treatment or Procedures," dated 08/2017 showed the following:
- Informed consent is a process by which a physician, or other allied health professional provided adequate information to a patient or a patient representative to allow the patient to make an informed decision about the proposed treatment, including medications, surgery or procedures to be performed by the person obtaining the consent;
- Informed consent shall generally be obtained before each new medical and surgical treatment or procedure;
- If the patient does not have the capacity to give informed consent or has been declared incompetent by a court, then another person must consent to or reject the proposed treatment on the patient's behalf; and
- A person may be considered not to have capacity to consent if he/she is incapable of understanding the risks, benefits, or nature of the proposed treatment or protocol due to impaired mental capacity as result of mental illness.

2. Record review of current Patient #4's History and Physical (H&P) showed the following:
- The patient was admitted on 08/30/17 for back pain related to an epidural (anesthetic, numbing procedure into the spinal column) abscess (a swollen area within body tissue, containing an accumulation of pus);
- History of schizophrenia (mental disorder that affects a person's ability to think, feel, and behave clearly) PICA (persistent eating of substances such as dirt or paint that have no nutritional value), borderline Personality Disorder (mental disorder in which you have a rigid and unhealthy pattern of thinking, functioning and behaving), self-inflicted abdominal stab wounds to his abdomen, frequent ingestion of inedible objects and recent progression of lower extremity numbness and weakness with the inability to move that will most likely cause the patient to be permanently paralyzed at the thoracic (chest) level;
- The patient had two sitters for safety at bedside;
- The patient resides at an area psychiatric facility;
- The patient informed staff a few days after admission that he had swallowed objects prior to admission. Endoscopic (nonsurgical procedure used to examine a person's digestive tract by use of a flexible tube with a light and camera under sedation) exam was performed on 09/07/17 and one plastic spoon was removed from the lower portion of the esophagus (connects the throat to the stomach) along with one plastic spoon from the stomach; and
- The patient ingested objects during his current admission and had another endoscopic exam performed on 10/24/17 with two plastic spoons and one plastic knife removed from the gastric fundus (the upper part of the stomach).

3. Record review of Patient #4's procedure consent dated 08/31/17 showed the procedure to be done was a T4-T5 (fourth and fifth thoracic [chest] vertebrae that make up the middle segment of the spinal column) bone biopsy (examination of tissue removed from a living body to discover the presence, cause or extent of a disease) that was signed by the patient.

Record review of a procedural consent for Central Venous Catheter (also known as a central line is a catheter placed into a large vein either in the veins in the neck, chest, groin or through veins in the arm that provides long-term port of entry into the body for fluids or nutrition) Placement dated 09/21/17 showed that the consent was signed by the patient.

Record review of two separate requests for upper endoscopy and consent one dated 09/07/17 and the other one dated 10/24/17 both showed a signature that was not the patient's and the relationship to patient stated "guardian".

During an interview on 10/25/17 at 10:02 AM, Patient #4, stated that he had a guardian and that he had lived at a psychiatric facility for the past seven years.

During an interview on 10/25/17 at 10:45 AM, Staff F, Registered Nurse, RN, stated that she was Patient #4's nurse for that day. She stated that Patient #4 did not have a guardian and that she knew what a Power of Attorney (the authority to act for another person in specified or all legal or financial matters) was but was unsure what a guardian was.

During an interview on 10/27/17 at 1:15 PM, Staff P, Fellow Resident (physician in training), stated that he was not aware that Patient #4 had a guardian. He stated that it was a judgement call if he felt that a patient could or couldn't give consent for procedures based on the patient's orientation (a state of being oriented to person, place, time and situation).

During an interview on 10/27/17 at 12:10 PM, Staff N, Chief Nursing Officer, stated that procedural consents should not be signed by patients that have guardians.

Based on interview, record review, and policy review, the facility failed to immediately remove staff from duty after allegations of potential abuse were voiced to the facility administrator on call (House Supervisor). This failure created an unsafe environment and had the potential to affect all patients admitted to the facility by placing them at risk for their safety. The facility census was 955.

Findings included:

1. Record review of the facility's policy titled, "Abuse/Neglect (Child/Disabled/Domestic/Elder/Patient Abuse)", dated 06/2016 showed the following:
- All patients in the facility will be protected from abuse by anyone including, but not limited to: staff, other patients, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individual;
- If the allegations are to have occurred in the facility, an internal investigation will immediately be initiated;
- All suspected or witnessed cases of abuse or neglect should be immediately reported through the appropriate channels;
- For allegations of abuse it will be the responsibility of the Patient Care manager, in conjunction with Public Safety, to initiate the investigation. During off hours and weekends the Nursing Supervisor will work in conjunction with Public Safety to initiate the investigation;
- The investigative team will follow the investigation procedure that contains specific investigation paths of interview parameters and reporting requirements; and
- Division Manager or Nursing Supervisor once made aware of the suspected patient abuse/neglect while in the facility will assist in completing the notification checklist for internal investigations involving a facility employee then removes the involved team member from the situation and initiates internal investigation by conducting interview with the involved team member then notifies human resources and discuss with employee that they will be on paid leave for the protection of the employee and the patient.

2. Record review of the undated facility document titled, "Department of Public Safety Training," showed the following information regarding Pressure Point Control Tactics (PPCT) System:
- Mandibular Angle Nerve Pressure Point: The Mandibular Angle is located behind the base of the ear lobe between the Mastoid [bone behind the ear] and the Mandible [jaw].
- The nerves affected are the hypoglossal [12th cranial nerve], vagus [the longest cranial nerve that contains motor and sensory fibers that passes through the neck and thorax to the abdomen] and the glossopharyngeal [ninth cranial nerve that exits the brainstem close to the vagus nerve] all which run together behind the mandible;
- Pressure should be directed in and forward toward the tip of the nose;
- The method of application is touch pressure;
- It is one of the most reliable pressure points in the PPCT;
- It's effectiveness makes it practical for controlling any type of resistance when the "officer" is in close proximity to the subject;
- The primary control principle is pain compliance; and
- Additional expected effects are "medium to high intensity pain," immediate signs of submission and probable cessation of all intentional motor activity.

3. Record review of Patient #4's History and Physical (H&P) dated 09/30/17, showed the following:
- Admission date of 08/30/17 with chief complaint of epidural (anesthetic, numbing procedure into the spinal column) abscess (a swollen area within body tissue, containing an accumulation of pus);
- History of schizophrenia (mental disorder that affects a person's ability to think, feel, and behave clearly), insulin-dependent diabetes (a chronic condition in which the body produces little to no insulin), high blood pressure, PICA (persistent eating of substances such as dirt or paint that have no nutritional value), small bowel obstruction, peptic ulcer disease (painful ulceration, erosion in the area of the upper gastrointestinal tract), borderline personality disorder (mental disorder in which you have a rigid and unhealthy pattern of thinking, functioning and behaving), multiple admissions for ingestion of metal objects, self-inflicted abdominal stab wounds after ostomy (artificial opening in an organ of the body created during surgery);
- Recent history of back pain and three days of lower extremity weakness and numbness;
- Denied any recent ingestion or self-harm and this was confirmed by his bedside sitter from the facility that he resides in;
- Admitting diagnosis was spinal cord compression;
- Multiple past admissions for foreign body ingestions, self-inflicted stab wounds; and
- Plan for sitter, no sharp objects in room or utensils with meals, psychiatric consult.

Record review of the facility document titled, "Department of Public Safety Incident Report," dated 10/15/17 at 9:51 PM completed by Staff L, Security Officer, showed the following documentation:
- Upon arrival Staff C, RN, informed security that Patient #4 was acting up, had tried to punch and spit on staff and attempted to rip his stomach suture (stitches) open;
- Staff Z, RN, was on one side of the patient's bed prepared to give the patient a shot of Thorazine (antipsychotic medication to treat mental illness and behavioral disorders) that the patient stated he didn't want and he attempted to punch Staff Z;
- Staff M, Security Officer, arrived and stood on the right side of the patient's bed and restrained the patient's right wrist and right shoulder;
- Staff H, Security Officer, held the patient's left shoulder and chin to prevent the patient from spitting;
- While security was holding the patient, nursing staff applied soft wrist restraints and they let go of the patient and left the room;
- While obtaining information from Staff C, RN, at the nursing station, Staff H, Security Officer, reported that he had to go back into Patient #4's room because he had loosened the soft wrist restraints and he was trying to open his stomach sutures again;
- Staff H, Security Officer, restrained Patient #4's left arm while Staff Z, RN, administered medication to the patient's left arm;
- Patient #4 then grabbed Staff H, Security Officer's, left hand with his right hand and refused to let go;
- Staff H, Security Officer, administered the mandibular angle under the jaw line to Patient #4's left side until he let go which was approximately three to five seconds;
- Patient #4 then spit at Staff H and started swinging his fists;
- Staff H, Security Officer, administered a second mandibular angle for approximately three to five seconds to the patients left side, under the jaw line, while giving loud and clear commands to Patient #4 that he needed to stop spitting and swinging his arms;
- Patient #4 started to calm down while Staff H was still restraining the patient's left arm, making sure he was going to fully comply with the verbal commands;
- Staff M, Security Officer, entered the room to assist Staff H by restraining the patient's right arm;
- Staff L, Security Officer, came back into the patient's room and restrained the patient's left wrist so that Staff H, Security Officer, could exit the room to speak with a supervisor;
- Staff W, House Supervisor, arrived to apply locked limb restraints (restraints used to control the behavior of a strong, violent and aggressive patient who could injure self, other patients and/or staff) to the patient;
- Patient #4 was compliant with the restraint application and with medication administration by nursing staff;
- Officers cleared the room once the patient received his medication and calmed down;
- Before officers cleared the scene, base called and informed them that the outside facility sitter (a sitter from an outside psychiatric facility where the patient resided) that was standing by had called her supervisor at the facility she worked for because she thought Staff H, Security Officer, was "abusing" the patient when he applied the mandibular angle;
- Staff Q, Security Officer, Charge Level, arrived on scene to assess the situation;
- All officers cleared and left the scene; and
- Staff W, House Supervisor, and Staff Q, Security Officer, "conferred and determined" abuse did not occur to the patient.

During a telephone interview on 10/25/17 at 2:10 PM, Staff C, RN, stated that she was assigned to care for Patient
#4 on 10/15/17 and that he had two sitters in his room, one male facility sitter and one female outside facility sitter. She stated that the patient had asked for a straw and when she told him he couldn't have straws he got very upset and agitated. She stated that she called Staff J, Physician, and medication and soft wrist restraints were ordered. Staff C stated that when the patient continued to become more upset she called security, Staff J, Physician, and Staff W, House Supervisor, to come assess and evaluate the situation. She stated that one of the sitters yelled out that the patient had threatened to kill "him". She stated that the patient was very explosive at this point and attempted to open up his stomach wounds. She stated that security had their hands on Patient #4's face trying to cover his mouth and that security then applied a surgical mask to help keep him from spitting.

During an interview on 10/25/17 at 12:45 PM, Patient #4 stated that he had become agitated and upset "last weekend" when he wasn't given a straw to drink out of. He stated that he had used a straw prior to then and didn't understand why he wasn't allowed to continue to use one. He stated that when he got upset he asked staff to place him in restraints because he knows he will try to hurt himself. Patient #4 stated that he had difficulty breathing when the security guard tried to put a mask on his face.

During an interview on 10/25/17 at 2:37 PM, Staff E, Facility Overtime Sitter (staff that were not regular sitters but held other positions within the facility and picked up extra hours as a sitter), stated that he was the facility sitter assigned for Patient #4 on 10/15/17. He stated that the patient had asked for a straw and when Staff C, RN, stated that he couldn't have one the patient became agitated. He stated that security came to the room and he informed them that the patient had spit on him. Staff E stated that nursing staff tried to give patient medication but the patient was so upset that security had to hold him by holding his arm and shoulder down. He stated that security also put a mask on the patients face to prevent him from spitting at staff by one security guard holding the patient's head while the other one put the mask on. Staff E stated that the patient continued to yell at him and security suggested that he leave the room. He stated that the outside facility sitter spoke out and stated that she felt the security guards were "roughing up the patient" but he did not report this to anyone as he felt nothing inappropriate had taken place.

During an interview on 10/25/17 at 4:05 PM, Staff H, Security Officer, stated that the patient had a hold of his left hand and wouldn't let go so he administered the mandibular angle pressure point to Patient #4's left side and the patient released and let go of his hand and then spit at him and swung his arms at him so he administered the mandibular angle pressure release a second time. He stated that another security officer came into the room and Staff H put his hand over the patient's mouth until a mask was retrieved to put over the patient's mouth so he wouldn't be able to spit. Staff H stated that he applied the mask over the patient's mouth while the other security officer held his head. Staff H stated that this was a "normal procedure" for this type of situation. He stated that after the event he and Staff W, House Supervisor, discussed what had occurred.

During a telephone interview on 10/27/17 at 9:24 AM, Staff Q, Security Officer, stated that he had received a call from base (security base office) that reported someone had called the local police department. He stated that upon his arrival to the floor Patient #4 was in locked limb restraints and he talked with Staff W, House Supervisor. Staff Q questioned Staff W if they were pursuing the incident as patient abuse and Staff W replied no. He stated that one nurse had reported that the outside facility sitter had called the local police department and one nurse reported that the sitter had called her supervisor at the other facility. Staff Q stated that Staff W had questioned the sitter and she stated that she called her supervisor and told them what had happened per their policy when hands were put onto a patient.

During a telephone interview on 10/27/17 at 2:30 PM, Staff W, House Supervisor, stated that she was the House Supervisor on the night of 10/15/17. She stated that she was called to the floor by staff and informed her security was there. She stated when she arrived to Patient #4's room there was two security guards there, one on each side of the patient's bed. Staff W stated that the patient was pulling very hard at the soft wrist restraints and attempted to reach his abdominal wound. She stated that when the soft wrist restraints didn't work the physician ordered locked limb restraints. Staff W stated that after the locked limb restraints were placed, one of the security guards informed her that the sitter had called somebody. Staff W stated that she questioned the outside facility sitter and asked her who she had called and the sitter replied that she had called her facility and informed them that the security guard was being rough with the patient . Staff W stated that she did not take the information she had received from the outside facility sitter as allegations of abuse based on what she, herself, had witnessed while she was in Patient #4's room. She stated that she was not in the patient's room when the security guards had their hands on the patient's face and she did not witness any pressure point release tactics.

Staff H, Security Officer, applied a tactic that had the expected effect of medium to high intensity pain with immediate signs of submission and probable cessation of all intentional motor activity to Patient #4 two times. Staff W, House Supervisor, was aware of the allegations of abuse but failed to initiate an investigation and remove Staff H from his responsibilities until an investigation had been completed. Staff W based her decision not to investigate on the fact that while she was in Patient #4's room she did not witness anything that she felt was abusive in nature. Staff W was not in Patient #4's room during the entire time of the event and did not witness Staff H, Security Officer when he applied the mandibular angle pressure point release tactic or other interactions between security and the patient. Staff E, Overtime Sitter failed to follow facility policy when he overheard the outside facility sitter voiced concerns that the security officer was being too rough with the patient.

Based on interview, record review and policy review, the facility failed to prevent staff to patient abuse of one current patient (#4) of one current patient reviewed for potential staff to patient abuse and initiate an investigation when allegations of staff to patient abuse (Patient #4) were reported. These failures had the potential to place all patients at risk for their safety. The facility census was 955.

Findings included:

1. Record review of the facility's policy titled, "Abuse/Neglect (Child/Disabled/Domestic/Elder/Patient Abuse)," dated 06/2016 showed the following:
- All patients in the facility will be protected from abuse by anyone including, but not limited to: staff, other patients, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individual;
- Physical abuse is non-accidental use of physical force that results in bodily injury, pain, or impairment;
- If the allegations are to have occurred in the facility, an internal investigation will immediately be initiated;
- All suspected or witnessed cases of abuse or neglect should be immediately reported through the appropriate channels;
- Internal investigation procedure it to immediately notify the Clinical Nurse/Department Manager and/or Nursing Supervisor, Public Safety then Risk Management. Documentation should be completed with the patient/witness disclosure and the submittal of an incident report to the Safety Event Management System (SEMS); and
- Upon notification from staff of suspected abuse/neglect by a facility employee, the Manager/Nursing Supervisor will complete the Administration Notification Checklist (notification checklist for internal investigations involving facility employee).

2. Record review of the undated facility document titled, "Department of Public Safety Training," showed the following information regarding Pressure Point Control Tactics (PPCT) System:
- Mandibular Angle Nerve Pressure Point: The Mandibular Angle is located behind the base of the ear lobe between the Mastoid [bone behind the ear] and the Mandible [jaw].
- The nerves affected are the hypoglossal [12th cranial nerve], vagus [the longest cranial nerve that contains motor and sensory fibers that passes through the neck and thorax to the abdomen] and the glossopharyngeal [ninth cranial nerve that exits the brainstem close to the vagus nerve] all which run together behind the mandible;
- Pressure should be directed in and forward toward the tip of the nose;
- The method of application is touch pressure;
- It is one of the most reliable pressure points in the PPCT; and
- It's effectiveness makes it practical for controlling any type of resistance when the "officer" is in close proximity to the subject;
- The primary control principle is pain compliance; and
- Additional expected effects are medium to high intensity pain, immediate signs of submission and probable cessation of all intentional motor activity.

3. Record review of Patient #4's History and Physical (H&P) dated 09/30/17, showed the following:
- Admission date of 08/30/17 with chief complaint of epidural (anesthetic, numbing procedure into the spinal column) abscess (a swollen area within body tissue, containing an accumulation of pus);
- History of schizophrenia (mental disorder that affects a person's ability to think, feel, and behave clearly), insulin-dependent diabetes (a chronic condition in which the body produces little to no insulin), high blood pressure, PICA (persistent eating of substances such as dirt or paint that have no nutritional value), small bowel obstruction, peptic ulcer disease (painful ulceration, erosion in the area of the upper gastrointestinal tract), borderline personality disorder (mental disorder in which you have a rigid and unhealthy pattern of thinking, functioning and behaving), multiple admissions for ingestion of metal objects, self-inflicted abdominal stab wounds after ostomy (artificial opening in an organ of the body created during surgery);
- Recent history of back pain and three days of lower extremity weakness and numbness;
- Denied any recent ingestions or self-harm and this was confirmed by his bedside sitter from the facility that he resides in;
- Admitting diagnosis was spinal cord compression;
- Multiple past admissions for foreign body ingestions, self-inflicted stab wounds; and
- Plan for sitter, no sharp objects in room or utensils with meals, psychiatric consult.

Record review of Patient #4's nursing incidental update note dated 10/16/17 at 1:51 AM showed:
- The patient had asked Staff C, Registered Nurse, (RN) for a straw and Staff C replied that he was not to have straws or utensils because of his history of swallowing things;
- Patient expressed that he had been allowed to have straws over the past couple of weeks;
- Staff C, RN, informed the patient that she would call the physician and see if it was okay for him to use straws and the patient became agitated and yelled at the RN and used inappropriate language;
- Patient asked to be placed into restraints;
- Security was notified;
- Patient continued to use inappropriate language and used racial comments towards Staff E, Facility Sitter, and spit on multiple staff and threatened to kill them;
- Security arrived and held the patient down while staff applied soft wrist restraints and also placed a mask on the patient to prevent him from spitting;
- Soft wrist restrains were unsuccessful because the patient released himself and attempted to open up his stomach wound;
- Security held the patient down while Staff C left to go notify the physician to come and assess the patient and the situation;
- Staff J, Physician, ordered to give patient Thorazine (antipsychotic medication to treat mental illness and behavioral disorders);
- Patient continued to be combative because he did not want the Thorazine;
- Staff J, Physician, arrived and ordered locked limb restraints (restraints used to control the behavior of a strong, violent and aggressive patient who could injure self, other patients and/or staff) and Ativan (sedative to treat anxiety);
- Hard restraints was placed on the patient and the Ativan was given intravenously (IV, within the vein); and
- Patient became calm and fell asleep.

Record review of the facility document titled, "Department of Public Safety Incident Report," dated 10/15/17 at 9:51 PM completed by Staff L, Security Officer, showed the following documentation:
- Upon arrival Staff C, RN, informed security that Patient #4 was acting up, had tried to punch and spit on staff and attempted to rip his stomach suture (stitches) open;
- Staff Z, RN, was on one side of the patient's bed prepared to give the patient a shot of throazine that the patient stated he didn't want and he attempted to punch Staff Z;
- Staff M, Security Officer, arrived and stood on the right side of the patient's bed and restrained the patient's right wrist and right shoulder;
- Staff H, Security Officer, held the patient's left shoulder and chin to prevent the patient from spitting;
- While security was holding the patient, nursing staff applied soft wrist restraints and they let go of the patient and left the room;
- While obtaining information from Staff C, RN, at the nursing station, Staff H, Security Officer, reported that he had to go back into Patient #4's room because the patient had loosened the soft wrist restraints and was trying to open his stomach sutures again;
- Staff H, Security Officer, restrained Patient #4's left arm while Staff Z, RN, administered medication to the patient's left arm;
- Patient #4 then grabbed Staff H, Security Officer's, left hand with his right hand and refused to let go;
- Staff H, Security Officer, administered the mandibular angle under the jaw line to Patient #4's left side until he let go which was approximately three to five seconds;
- Patient #4 then spit at Staff H and started swinging his fists;
- Staff H, Security Officer, administered a second mandibular angle for approximately three to five seconds to the patients left side, under the jaw line, while giving loud and clear commands to Patient #4 that he needed to stop spitting and swinging his arms;
- Patient #4 started to calm down while Staff H was still restraining the patient's left arm, making sure he was going to fully comply with the verbal commands;
- Staff M, Security Officer, entered the room to assist Staff H by restraining the patient's right arm;
- Staff L, Security Officer, came back into the patient's room and restrained the patient's left wrist so that Staff H, Security Officer, could exit the room to speak with a supervisor;
- Staff W, House Supervisor, arrived to apply locked limb restraints to the patient;
- Patient #4 was compliant with the restraint application and with medication administration by nursing staff;
- Officers cleared the room once the patient received his medication and calmed down;
- Before officers cleared the scene, base called and informed them that the outside facility sitter (a sitter from an outside psychiatric facility where the patient resided) that was standing by had called her supervisor at the facility she works for because she thought Staff H, Security Officer, was "abusing" the patient when he applied the mandibular angle;
- Staff Q, Security Officer, Charge --arrived on scene to assess the situation;
- All officers cleared and left the scene; and
- Staff W, House Supervisor, and Staff Q, Security Officer, "conferred and determined" abuse did not occur to the patient.

During a telephone interview on 10/25/17 at 2:10 PM, Staff C, RN, stated that she was assigned to care for Patient #4 on 10/15/17 and that he had two sitters in his room, one male facility sitter and one female outside facility sitter. She stated that the patient had asked for a straw and when she told him he couldn't have straws he got very upset and agitated. She stated that she called Staff J, Physician, and medication and soft wrist restraints were ordered. Staff C stated that when the patient continued to become more upset she called security, Staff J, Physician, and Staff W, House Supervisor, to come assess and evaluate the situation. She stated that "one sitter" yelled out that the patient had threatened to kill "him". She stated that the patient was very explosive at this point and attempted to open up his stomach wounds. She stated that security had one hand on Patient #4's face trying to cover his mouth and applied a surgical mask to prevent him from spitting.

During an interview on 10/25/17 at 12:45 PM, Patient #4 stated that he had become agitated and upset "last weekend" when he wasn't given a straw to drink out of. He stated that he had used a straw prior to then and didn't understand why he wasn't allowed to continue to use one. He stated that when he got upset he asked staff to place him in restraints because he knows he will try to hurt himself. Patient #4 stated that he had difficulty breathing when the security guard tried to put a mask on his face.

During an interview on 10/25/17 at 2:37 PM, Staff E, Facility Overtime Sitter (staff that were not regular sitters but held other positions within the facility and picked up extra hours as a sitter), stated that he was the facility sitter assigned for Patient #4 on 10/15/17. He stated that the patient had asked for a straw and when Staff C, RN, stated that he couldn't have one the patient became agitated. He stated that security came to the room and he informed them that the patient had spit on him. Staff E stated that nursing staff tried to give patient medication but the patient was so upset that security had to hold him by holding his arm and shoulder down. He stated that security also put a mask on the patient's face to prevent him from spitting at staff while one security officer held the patient's head while the other security officer placed the mask on. Staff E stated that the patient continued to yell at him and security suggested that he leave the room. He stated that the outside facility sitter spoke out and stated that she felt the security guards were "roughing up the patient" but he did not report this to anyone as he felt nothing inappropriate had taken place.

During a telephone interview on 10/26/17 at 2:10 PM Staff Z, RN, stated that he had cared for Patient #4 during his current admission but was not assigned to him on 10/15/17. He stated that he helped Staff C, RN, with medication administration when the patient was very agitated and upset. He stated that he was in the patient's room when security applied a mask on the patient's face to prevent him from spitting. Staff Z stated that after the event he was across the hall with another patient and the outside facility sitter was out in the hallway on her cellular phone. He stated that he overheard her say "I'd like to report something." He stated he wasn't sure who she had called but reported what he had heard to Staff W, House Supervisor.

During an interview on 10/25/17 at 4:05 PM, Staff H, Security Officer, stated that the patient had hold of his left hand and wouldn't let go so he administered the mandibular angle pressure point to Patient #4's left side and the patient released and let go of his hand and then spit at him and swung his arms at him so he administered the mandibular angle pressure release again. He stated that another security officer came into the room and Staff H put his hand over the patient's mouth until a mask was retrieved to put over the patient's mouth so he wouldn't be able to spit. Staff H stated that he applied the mask over the patient's mouth while the other security officer held his head. Staff H stated that this was "normal procedure" for this type of situation. He stated that after the event he and Staff W, House Supervisor, discussed what had occurred.

During a telephone interview on 10/27/17 at 9:24 AM, Staff Q, Security Officer, stated that he had received a call from dispatch that reported someone had called the local police department. He stated that upon his arrival to the floor Patient #4 was in locked limb restraints and he talked with Staff W, House Supervisor. Staff Q questioned Staff W if they were pursing at that time a patient abuse and Staff W replied no. He stated that one nurse had reported that the outside sitter had called the local police department and one nurse reported that the sitter had called her supervisor at the other facility. Staff Q stated that Staff W had questioned the outside facility sitter and she stated that she called her supervisor and told them what had happened per their policy when hands were put onto a patient.

During a telephone interview on 10/27/17 at 10:15 AM, Staff R, Psychiatrist, from an outside facility stated that their sitter had reported that security had put their hand over Patient #4's mouth and turned the patient's head away from staff and that they leaned on the patient with their forearms pushing the patient's face into the pillow. He stated that after the shift the sitter checked in with Staff W, House Supervisor, and told her she was concerned. Staff R stated that he had spoken to Staff S, facility Physician, regarding the event with Patient #4 and Staff S informed him that he had not heard of anything but he would handle the situation with security and that he didn't believe anyone used abusive or unnecessary roughness.

During a telephone interview on 10/27/17 at 2:30 PM, Staff W, House Supervisor, stated that she was the House Supervisor on the night of 10/15/17. She stated that she was called to the floor by staff that informed her security was there. She stated when she arrived to Patient #4's room there were two security guards there, one on each side of the patient's bed. Staff W stated that the patient was pulling very hard at the soft wrist restraints and attempted to reach his abdominal wound. She stated that when the soft wrist restraints didn't work the physician ordered locked restraints. Staff W stated that after the locked limb restraints were placed one of the security guards informed her that the sitter had called somebody. Staff W stated that she questioned the outside facility sitter and asked her who she had called and the sitter replied that she had called her facility and informed them that the security guard was being rough. Staff W stated that she did not take the information she had received from the outside facility sitter as allegations of abuse based on what she, herself, had witnessed while she was in Patient #4's room. She stated that she was not in the patient's room when the security guards had their hands on the patient's face and she did not witness any pressure point release tactics.

Staff H, Security Officer applied a tactic that had the expected effect of medium to high intensity pain with immediate signs of submission and probable cessation of all intentional motor activity to Patient #4. Staff W, House Supervisor, failed to initiate an investigation, per facility policy, when she was informed of allegations of staff to patient abuse by a facility RN and when the outside facility sitter verbalized concerns that the security officer was too rough with the patient. Staff W based her decision not to investigate on the observations she had made while in the patient's room. Staff W was not in the patient's room when security performed the pressure release point tactic and did not witness all of the interactions between the security guards and the patient.

Based on observation, interview, record review and policy review, the facility failed to ensure nursing staff monitored and observed one self-injurious patient (#4) with a sitter of one self-injurious patient with a sitter reviewed who successfully ingested inedible objects when he swallowed two plastic spoons and one plastic knife while a patient on the medicine and general surgery floor. (Refer to A-0395) This failure had the potential to place all patients admitted to the facility with self-injurious behavior at risk for their safety. The facility's census of self-injurious behavior patients was 4. The facility census was 955.

The severity and cumulative effect of these systemic practices resulted in the overall non-compliance with 42 CFR 482.23 Condition of Participation: Nursing Services and resulted in a condition of Immediate Jeopardy (IJ).

As of 10/27/17 at the time of the survey exit, the facility provided an immediate action plan sufficient to remove the IJ when the facility implemented the following actions:
- Immediate validation of safety of current self-injurious patients:
- Immediately rounded on all in-house patients currently designated as self-injurious with 1:1 sitters. Items reviewed and RN/sitter re-educated to:
1. Sitter awareness of patient specific self-injurious behaviors and what to observe for and report.
2. Assessment of patient room to validate that safety measures, as appropriate, are currently in place.
- Self-Injurious Policy Refresher Education:
- Refresher education on management of self-injurious patient behavior, including patient assessment, actions to implement and document requirements as outlined in Self-Injurious Policy.
1. Refresher education points delivered to Directors and Managers on 10/26/17.
2. Managers to communicate refresher education points to current staff working; and to educate oncoming evening and night shift staff prior to starting their shifts.
3. All staff to be educated by Tuesday, November 1, 2017; staff on FMLA (Family Medical Leave of Absence) or Time Off to be educated prior to the start of first shift returning.
- RN to Sitter and Sitter to Sitter Communication Tool: Revision of patient safety observation log to include on the reverse side of the communication tool that identifies patient-specific behaviors to monitor, risks that remain in the patient room, and patient-specific preferences for enhancing comfort and relaxation.
- Oversight of Sitters: Beginning 10/27/2017 Nurse Manager, Assistant Nurse Manager, and House Supervisor to round on patients with 1:1 sitters every two hours to:
- Ensure the sitter is monitoring and supervising the patient as expected by discussion with the sitter and reviewing the sitter observation log on correct/complete documentation.
- Ensure the sitter has the Communication Tool in their possession and discuss with sitter to verify they have awareness and understanding of the patient-specific information they need to effectively monitor their patient.
- Rounding will continue every two hours for two weeks; then will be conducted daily on alternating shifts every four hours until re-visit.
- Communication of Self-Injurious Status:
- Created visual symbol that will identify patients at risk of self-injurious behavior.
- Symbol will be placed on patient room doors 10/26/17 to serve as notification to all staff members, including outside agency staff and visitors, to speak to nursing staff before entering patient room regarding specific precautions.
- Education on use and meaning of symbol provided to all staff on 10/26/17.



18018

Based on observation, interview, record review and policy review, the facility failed to ensure nursing staff monitored and observed one self-injurious patient (#4) with a sitter of one self-injurious patient with a sitter reviewed who successfully ingested inedible objects when he swallowed two plastic spoons and one plastic knife while a patient on the medicine and general surgery floor. This failure had the potential to place all patients admitted to the facility with self-injurious behavior at risk for their safety. The facility's census of self-injurious behavior patients was 4. The facility census was 955.

Findings included:

1. Record review of the facility's policy titled, "Patient Safety Assistants: Guidelines for Requesting and Utilizing Patient Safety Assistants (Sitters)," dated 06/2017 showed:
- The purpose is to provide a process for objectively assessing and determining when to appropriately utilize a Patient Safety Assistant (PSA);
- The PSA is an employee who is responsible for staying with an assigned patient (s) for a specified amount of time to ensure patient safety;
- The PSA is to report to the Registered Nurse, (RN) on the unit assigned;
- The PSA is to remain alert at all times. Use of cell phone, watching television, reading or eating is prohibited;
- The PSA is to sit in the patient's room and observe the patient constantly;
- The PSA is to make sure view of patient is unobstructed and remains physically close to the patient;
- The PSA is to stay in the patient's room unless given approval to leave by the RN;
- The PSA is to know what precautions are necessary in caring for the patient; and
- The RN has ultimate responsibility for patients being observed by a PSA.

2. Observation on 10/25/17 at 10:02 AM showed Patient #4 lying in his bed with two sitters in the room with him. One sitter was his outside facility sitter (a sitter from an outside psychiatric facility where the patient resided) seated in a chair approximately one to two feet from the patient on the left side of his bed and the facility sitter seated in a chair in the corner approximately five to six feet from his beside to the right of the bed. There was a bedside table to the left of the patient at the head of the bed approximately one to two feet from the bedside. The over the bed table was positioned against the wall to the left of the bed in front of the outside facility sitter. Both sitters were watching television with the patient upon entrance into the room. The outside facility sitter had her purse on her lap and the facility sitter had a backpack.

3. During an interview on 10/25/17 at 10:05 AM Patient #4 stated that he had been at the facility for more than two months for back pain. He stated that he does bad things to himself when he gets mad or upset. He stated that he had swallowed some plastic silverware a week ago because he had gotten mad because a nurse wouldn't let him have a straw when other nurses allowed him to use straws. Patient #4 stated that he got the silverware from his bedside table.

4. During an interview on 10/25/17 at 10:25 AM, Staff Y, facility sitter, stated that nursing staff relieved her for lunch and bathroom breaks. She stated that she was a regular sitter but some staff that also worked other departments sometimes worked as a sitter to pick up extra hours and they were referred to as "overtime sitters."

5. During an interview on 10/25/17 at 10:30 AM, Staff X, outside facility sitter, stated that nursing did not relieve her for lunch or bathroom breaks and that she tried to wait and go to the bathroom when nursing was in the room. She stated that she didn't leave the room for lunch.

6. Record review of Patient #4's History and Physical (H&P) dated 09/30/17, showed the following:
- Admission date of 08/30/17 with chief complaint of epidural (anesthetic, numbing procedure into the spinal column) abscess (a swollen area within body tissue, containing an accumulation of pus);
- History of schizophrenia (mental disorder that affects a person's ability to think, feel, and behave clearly), insulin-dependent diabetes (a chronic condition in which the body produces little to no insulin), high blood pressure, PICA (persistent eating of substances such as dirt or paint that have no nutritional value), small bowel obstruction, peptic ulcer disease (painful ulceration, erosion in the area of the upper gastrointestinal tract), borderline personality disorder (mental disorder in which you have a rigid and unhealthy pattern of thinking, functioning and behaving), multiple admissions for ingestion of metal objects, self-inflicted abdominal stab wounds after ostomy (artificial opening in an organ of the body created during surgery);
- Recent history of back pain and three days of lower extremity weakness and numbness;
- Denied any recent ingestions or self-harm and this was confirmed by his bedside sitter from the facility that he resides in;
- Admitting diagnosis was spinal cord compression;
- Multiple past admissions for foreign body ingestions, self-inflicted stab wounds; and
- Plan for sitter, no sharp objects in room or utensils with meals, psychiatric consult.

Record review of Patient #4's physician progress notes dated 09/08/17 showed that the patient had underwent endoscopic (non-surgical procedure used to examine a person's digestive tract by use of a flexible tube with a light and camera) removal of two plastic spoons from his esophagus (connects the throat to the stomach) and stomach the previous day.

Record review of the patient's upper gastrointestinal endoscopy report dated 09/07/17 showed that the patient had the procedure for removal of a foreign body in the esophagus and in the stomach. A plastic spoon was found in the lower third of the esophagus and a plastic spoon was found in the stomach. Both items were removed without complications.

During an interview on 10/25/17 at 11:30 AM Staff A, Assistant Nurse Manager, stated that a couple days after his admission Patient #4 had informed her that he had ingested some objects at the facility where he resided and that they were causing him some problems. Staff A stated that he had an endoscopy procedure and some plastic utensils were removed. She stated that he had again ingested utensils sometime within the previous week or two and that he had undergone another endoscopy procedure for the removal the previous day. Staff A stated that the patient wasn't allowed to eat with plastic utensils but that she thought the sitters from the facility where he resided brought them in for their personal meals.

Record review of patient's upper gastrointestinal endoscopy report dated 10/24/17 showed that the patient had the procedure for removal of foreign body in the stomach. Two plastic spoons and one plastic knife were found in the gastric fundus (the upper portion of the stomach) were removed without complication.

During an interview on 10/25/17 at 10:45 AM Staff F, RN, stated that she was assigned to care for Patient #4 and that she was not aware that he had swallowed plastic utensils since he had been a patient at the facility. She stated that he always had two sitters in the room with him.

During an interview on 10/26/17 at 2:10 PM, Staff Z, RN, stated that he was aware that the patient had a history of ingesting objects and that he made sure a light was on in the patient's room at night. Staff Z also stated that the patient had informed staff that that he had swallowed two spoons and one knife but he wasn't sure how true that was or how he would have obtained the utensils. Staff Z stated that he was aware that the outside facility sitters ate their meals inside the patients' room.

During an interview on 10/25/17 at 2:37 PM, Staff E, Overtime Sitter, stated that he worked as a sitter to pick up extra hours but that wasn't his normal position at the facility. He stated that he had been the facility sitter for Patient
#4 multiple times during his current admission. Staff E stated that he was aware that the patient had a history of ingesting objects but he was not aware that the patient had ingested any objects during this admission.

During an interview on 10/25/17 at 3:30 PM, Staff A, Assistant Nurse Manager, stated that after Patient #4 ingested the plastic utensils, during his current admission, she stated that the patient informed her that he had found the utensils on his bedside table in his room. She stated that she was unaware of the exact date of the ingestion because the patient kept changing his story. She stated that the facility sitters left the room for meals and facility staff took their place as sitter but outside facility sitters stayed in the room for meals. She stated that they were "not our employees" so they did not document who they were and the facility staff did not take their place as the sitter if they needed a bathroom or lunch break. Staff A stated that she had informed the staff what "she saw" regarding the ingestion of the plastic utensils but hadn't informed all staff that cared for the patient.

Patient #4 successfully ingested two plastic spoons and one plastic knife with two patient safety sitters in his room. Facility staff were unaware he had ingested any items during his current admission.