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Based on interviews and review of the facility's policies and procedures, it was determined the facility failed to provide care to patients in a safe setting for one (1) sampled patient (#10). On 02/04/17, Mental Health Technician (MHT) #1 placed Patient #10 in an improper physical hold which resulted in physical injury to the patient.

The findings include:

Review of the facility's policy and procedure titled "Seclusions and Restraints of Patients", revised 01/11/16, revealed non-physical interventions were utilized to de-escalate patients and were the preferred interventions in all cases.

Review of the "Nonviolent Crisis Intervention" training manual, dated 07/16, revealed a facedown (prone) floor restraint and any position in which the person is bent over in such a way that is difficult to breathe were extremely dangerous. Continued review revealed when someone is lying face down, even pressure to the arms and legs could impact that person's ability to breathe effectively.

Review of the facility's "Position Description for Mental Health Tech", undated, revealed the MHT should continuously observe patients' behavior, mental status and activities, and notify the RN of any changes or unusual occurrences. Continued review revealed the MHT should be able to assist with restraining a patient and placing a patient in seclusion utilizing proper crisis intervention technique.

Review of the facility's "Position Description for Registered Nurses", undated, revealed the RN was to continuously observe patients' behavior, mental status, and activities.

Review of Patient #10's medical record revealed the facility admitted the patient on 02/03/17 with a diagnosis of Disruptive Mood Dysregulation Disorder (a condition of extreme irritability, anger, and frequent, intense temper outbursts). Continued review of the medical record revealed a Pedi Progress Note, dated 02/05/17 and signed by the Physician, revealed diagnoses of Concussion, Superficial Abrasions, and Right Knee Pain related to the incident on 02/04/17.

Review of the facility's report of the incident, dated 02/08/17, revealed on 02/04/17 MHT #1 performed a physical intervention on Patient #10 which resulted in injuries to the patient. Per the facility's interview with a patient witness, MHT #1 grabbed Patient #1 around the waist from behind, and slammed him/her to the floor, causing the patient to hit his/her head on the floor. After MHT #1 had the patient on the floor, he put the patient's arms behind his/her back and held them in place with his knee. Per the facility's interview with MHT #1 he stated. "it wasn't nice, but I didn't slam him". He further explained he did have the patient on the ground, face down, with arms restrained. Further review of the report revealed both Registered Nurse (RN) #1 and RN #2 were off the unit and MHT #1 was left alone and unsupervised on the West Unit; therefore, there was no available staff to assist MHT #1 with crisis intervention for patient #10.

Interview with MHT #1, on 02/23/17 at 11:15 AM, revealed at the time of the incident, he was by himself on the unit with the door closed on the wing he was assigned. He stated the nurses were off the floor, and the MHT working on the other wing was not able to hear him call for help. MHT #1 reported Patient #10 exhibited a violent physical outburst which included throwing items and attempting to hit and kick the MHT. He stated he did not have a lot of options and felt Patient #10's behavior was an unsafe situation for the MHT and other residents on the unit. Continued interview revealed MHT #1 grabbed Patient #10, pinning the patient's arms to his side, and took the patient to the ground, face down, for better control. MHT #1 acknowledged Patient #10's arms were restrained and he/she was not able to move once on the ground.

Further review of the facility's "Investigative Report" related to the incident on 02/04/17 revealed the facility concluded MHT #10 violated facility policies and procedure by performing physical intervention without staff assistance, performing unauthorized, non-approved physical intervention technique, and physican intervention performed wihtout prior knowledge or approval by the unit nurse. The report did not address the absence of both unit nurses from the unit when a crisis situation erupted.

Interview with RN #2, on 02/23/17 at 9:05 AM, revealed when he and RN #1 returned to the unit, he saw MHT #1 on the floor with Patient #10. RN #2 stated MHT #1 backed away from Patient #10, and RN #2 was able to walk Patient #10 to the seclusion room to try and calm him down.

Interview with the Director of Nursing (DON), on 02/22/17 at 4:00 PM, revealed he was contacted by staff following the incident on 02/04/17. The DON stated he discussed the situation with MHT #1 regarding using an unauthorized hold. He further stated he felt MHT #1 might have overreacted, but did not feel it was abuse. Continued interview revealed the DON would have taken MHT #1 off the floor if he thought MHT #1 was actually trying to hurt someone. Furthermore, the DON also stated he was not familiar with the facility's abuse policy.

Interview with the facility's Chief Elected Officer (CEO), on 02/23/17 at 8:40 AM, revealed the physical hold MHT #1 placed on Patient #10 on 02/04/17 was a restraint. The CEO stated his expectation was for staff to follow the facility's policies and procedures to ensure a safe environment for the patients.

Based on interviews, record review and review of the facility's policies and procedures, it was determined the facility failed to ensure restraints or seclusions were properly used according to facility policy, and in accordance with State Law for one (1) sampled patient (#10). On 02/04/17, Mental Health Technician (MHT) #1 imposed a physical hold on Patient #10 which was not authorized by facility policy or crisis intervention guidelines. As a result, Patient #10 sustained abrasions, a sore knee and a concussion which did not require hospitalization.

The findings include:

Review of the facility's policy titled "Seclusion and Restraint of Patients" revised 06/14/16, revealed the use of seclusion and/or restraints should be avoided to every extent possible and staff should strive to prevent, reduce and potentially eliminate the use of this emergency intervention. Continued review revealed a time-limited physician's order was required prior to secluding or restraining a patient. In the event of an emergency situation, in the absence of a Physician or Advanced Practice Registered Nurse (APRN), the RN on duty could assess the need for, and initiate a seclusion/restraint in an effort to preserve the safety and integrity of the patients and staff. Further review revealed the RN was to contact the Physician or APRN immediately and obtain an order, within one hour of the initiation of the seclusion/restraint.

Review of the medical record revealed the facility admitted Patient #10 on 02/03/17 with a diagnosis of Disruptive Mood Dysregulation Disorder (a condition of extreme irritability, anger, and frequent, intense temper outbursts). Review of the signed Physician's progress note, dated 02/05/17, revealed Patient #10 sustained a Concussion, Superficial Abrasions, and Right Knee Pain as a result of the incident on 02/04/17.

Review of the facility's written report of the incident, dated 02/08/17, revealed Mental Health Tech (MHT) #1 performed an unapproved physical intervention on a patient which resulted in injuries to the patient. Continued review revealed the facility's policy and procedures regarding physical interventions mandates having two staff members involved.

Further review of the medical record revealed no documented evidence the Physician was notified or an order obtained for the emergency physical restraint until 02/07/17. Review of the Seclusion/Restraint Order Form, dated 02/07/17 at 11:14 AM, revealed Patient #10 was placed in a manual restraint for five (5) minutes on 02/04/17 at 5:30 PM.

Interview with RN #2, on 02/23/17 at 9:05 AM, revealed when he and RN #1 returned to the unit, he saw MHT #1 on the floor with Patient #10 in a physical hold. RN #2 stated he did not think the physical hold placed on Patient #10 by MHT #1 was a restraint. RN #2 further stated he could not remember if he contacted the physician on-call to obtain an order for the physical hold.

Interview with the DON, on 02/22/17 at 4:00 PM, revealed when placing hands on a patient, the staff must have an order to do so. The DON stated the staff should have documented the physical hold in the chart but stated the staff may have forgotten. The DON further stated MHT #1's intervention with Patient #10 was a physical hold, not a restraint, and an evaluation within the first hour was not needed for a physical hold.

Interview with the Physician On-call, on 02/23/17 at 9:45 AM, revealed the facility staff did not contact him on the evening of 02/04/17 and he did not give any orders for a restraint/seclusion on that date. The Physician On-Call stated he was informed of the incident on 02/05/17.

Interview with the Medical Director, on 02/22/17 at 10:35 AM, revealed he was notified of the incident on 02/04/17 but was not the physician on-call. The Medical Director stated the staff should have notified the physician on-call to obtain the order for a restraint. Continued interview revealed the on-call must have forgotten to enter the order in the system, so the Medical Director placed the order on 02/07/17.

Interview with the facility's Chief Elected Officer (CEO), on 02/23/17 at 8:40 AM, revealed the physical hold MHT #1 placed on Patient #10 on 02/04/17 was a restraint. The CEO stated the nurse should have contacted the physician on-call and obtained an order for the physical hold. The CEO further stated his expectation was for staff to follow the facility's policies and procedures to ensure a safe environment for the patients.

Based on interview, record review and review of the facility's policies and procedures, it was determined the facility failed to ensure two (2) of ten (10) sampled patients (#2 and #10) were seen face-to-face by the Physician, Advanced Practice Registered Nurse (APRN) or an RN within 1 hour after the initiation of a crisis intervention, in order to complete a physical and behavioral assessment.
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The findings include:

Review of the facility's policy titled "Seclusions and Restraints of Patients", revised 01/11/16, revealed within one hour of the initiation of seclusion and/or restraint, a documented evaluation of the following must be performed by a Physician, APRN, or RN who has been trained to evaluate the following: the patient's immediate situation; the patient's reaction to the intervention; the patient's medical and behavioral condition; and the need to continue or terminate the restraint.

Review of Patient #2's medical record revealed the facility admitted the patient on 02/14/17 with diagnoses of Attention-Deficit/Hyperactivity Disorder and Post Traumatic Stress Disorder.

Review of the Seclusion/Restraint Order Form, dated 02/14/17 at 7:44 PM, revealed staff obtained a manual restraint order from the Medical Director for Patient #2. Continued review of the form revealed no evaluation was performed within one (1) hour of the initiation of the restraint.

Review of the Seclusion/Restraint Order Form, dated 02/18/17 at 3:39 PM, revealed staff manually escorted Patient #2 to the seclusion room and closed the door, secluding the patient in the room. Continued review revealed no evaluation of the patient's physical or psychological status was documented.

Review of Patient #10's medical record revealed the facility admitted the patient on 02/03/17 with a diagnosis of Disruptive Mood Dysregulation Disorder (a condition of extreme irritability, anger, and frequent, intense temper outbursts.)

Review of the Seclusion/Restraint Order Form, dated 02/07/17 at 11:14 AM, revealed Patient #10 was placed in a manual restraint for five (5) minutes on 02/04/17 at 5:30 PM until 5:35 PM. Continued review of the form revealed no evaluation of the patient's status was documented within the first hour.

Interview with RN #2, on 02/23/17 at 9:05 AM, revealed he has not had any specific training in performing the evaluation of a patient within one (1) hr of a restraint or seclusion. RN #2 further stated he did not know an evaluation had to be performed when a patient was placed in a therapeutic hold.

Interview with the DON, on 02/23/17 at 10:30 AM, revealed he was unaware a manual restraint needed an evaluation within one (1) hr after the restraint was initiated. The DON stated there was no education provided to the staff regarding Restraints and Seclusions except that related to the crisis intervention training provided by the Lead MHT during orientation. The DON further stated the RNs are not given any additional training on how to perform the evaluation.

Interview with the facility's Chief Elected Officer (CEO), on 02/23/17 at 8:40 AM, revealed staff should be following the regulations regarding all seclusions and restraints and should be performing evaluations within one (1) hr of all restraints and/or seclusions.

Based on interview and review of the facility's policies and procedures, it was determined the facility failed to ensure the Registered Nurse (RN) provided ongoing supervision of patients under their care. On 02/04/17, Mental Health Technician (MHT) #1 was alone on his wing of the West Unit, while the two (2) Registered Nurses (RNs) were off the unit. During their absence, Patient #10 required emergency crisis intervention and MHT #1 placed the patient on the floor in a facedown position, restraining the patients arms and preventing movement. Patient #10 sustained abrasions to the face, a sore knee and a concussion which did not require hospitalization.

The findings include:

Review of the facility's policy titled "Staffing Pattern", revised date of 06/14/16, revealed the initial staffing pattern at the time of schedule preparation is designed to have at least one (1) staff member for every (5) patients, and at least one (1) RN on duty at all times.

Review of the facility's policy titled "Seclusions and Restraints of Patients", revised 01/11/16, revealed there should be adequate staffing to maintain a safe environment for both patients and staff, and to reduce the need for physical holds.

Review of the facility's "Position Description for Mental Health Tech", undated, revealed the MHT should continuously observe patients' behavior, mental status and activities, and notify the RN of any changes or unusual occurrences. Continued review revealed the MHT should be able to assist with restraining a patient utilizing proper crisis intervention technique.

Review of the facility's "Position Description for Registered Nurses", undated, revealed the RN's duty to continuously observe the patients' behavior, mental status, and activities.

Review of the facility's "Investigative Report", dated 02/06/17, revealed MHT #1 performed a physical intervention on Patient #10, which resulted in injuries to the patient. Further review of the report revealed RN #1 and RN #2 were both off the unit and MHT #1 was left alone on the West Unit unsupervised. Continued review of the conclusions and recommendations resulting from the report revealed MHT #1 violated facility policy by: performing physical intervention without staff assistance; performing unauthorized, non-approved physical intervention technique, and performing physical intervention without prior knowledge or approval by the unit nurse.

Interview with MHT #1, on 02/23/17 at 11:15 AM, revealed at the time of the incident, he was by himself on the unit with the door closed on the wing he was assigned. MHT #1 stated both of the nurses were off the floor and the other MHT working on the other wing was not able to hear him call for help. MHT #1 stated he felt his options were limited in what in his opinion was an unsafe situation for himself and the other patients.

Interview with MHT #2, on 02/23/17 at 12:20 PM, revealed the unit was not always well staffed which could impact the safety of the patients, as well as the staff. MHT #2 stated at times the RN on the unit would have to leave for some reason, leaving the unit without a nurse. MHT #2 further stated at times, other staff members have to be pulled from their offices to the unit to help with coverage.

Interview with RN #1, on 02/22/17 at 10:00 AM, revealed at times, the RN would have to leave the unit for admissions or to talk with parents, or for other patient related issues. RN #1 stated the facility recently had 2 nurses resign and another nurse was out on medical leave. RN #1 further stated unit staff should have a two-way radio with them, and should contact the nurse if needed. Continued interview revealed sometimes the nurse had to be off the unit 45 minutes to an hour.

Interview with RN #2, on 02/23/17 at 09:05 AM, revealed if only one RN was working the unit, he/she may have to leave to perform other tasks such as admitting a new patient to the unit.

Interview with the DON, on 02/23/17 at 10:30 AM,revealed all staff should have their two-way radios with them at all times, even if the nurse did not have to leave the unit, in order to request assistance if needed. The DON further stated other licensed staff are asked at times to help provide coverage to the unit during breaks and at other times when needed.