The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

FAITH REGIONAL HEALTH SERVICES 2700 WEST NORFOLK AVE NORFOLK, NE 68701 July 12, 2012
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observation, medical record reviews, staff interviews, review of the facility internal investigation, review of the video record from the Intensive Psychiatric Care (IPC) unit, and review of the facility's policies and procedures, the facility failed to provide patient care in a safe setting. This failure resulted in the finding of the Condition of Participation for Patient Rights out of compliance. In a sample of 10 patients, 5 patients were selected from the psychiatric programs. Sampled Patient 1 suffered injury because the facility failed to ensure adequate numbers of trained staff were available at all times to meet the needs of psychiatric patients. This resulted in an insufficient number of staff available to safely handle a psychiatric emergency situation at 6:27 AM on 5/17/12 when Patient 1 was agitated, manic, and losing self-control. The facility also failed to ensure sampled Patient 1 was protected from staff abuse, and failed to ensure that staff present at that time reported the abuse within the 24 hour time frame as directed in facility policy and procedure leaving patients at continued risk for abuse. The Facility census on the day of entrance was 52 including 16 patients on the 2 Behavioral Health Services units housed in a building on a separate campus. Findings are:

Tour on 7/11/12 beginning at 3:35 PM on the psychiatric programs (Behavioral Health Services-BHS) units (housed on a separate campus approximately 1 mile away from the main campus) found there were 2 units, the IPC unit and the Progressive Psychiatric Care Unit (PPC). The facility accepts EPC (Emergency Protective Custody) patients on the IPC unit (EPC patients are involuntary admissions placed there by law enforcement officers when they are a danger to themselves or others). On the night shift the building is empty except for the nursing staff on IPC and PPC units along with 1 security officer in the building. In an interview with the Director of Behavioral Health on 7/11/12 during the tour, it was determined that the security staff had not been trained in psychiatric restraint application or assisting staff with the hands on placing of an out-of-control patient in seclusion or restraint. It was also revealed that the staffing for the night shift (6:45 PM to 7:15 AM) is based on census of the units resulting in some night shifts with just 4 nursing staff that would include 1 Registered Nurse (RN), another RN or Licensed Practical Nurse (LPN), and 2 Behavioral Techs to cover both units. During the night shift ending at 7:15 AM on 5/17/12, the facility had staffed the 2 units with a total of 4 staff (1 RN, 1 LPN and 2 Behavioral Techs). To safely attend to an out-of-control patient, acceptable standard of practice, requires 5 staff members (1 trained RN to direct the staff and the patient, and 4 other trained staff, with each staff assigned to an extremity). In addition, 1 staff is needed on each unit to monitor and watch the other patients. During the tour it was found that the facility did have video cameras on both units, potentially allowing 1 staff member to watch the monitor from the nurse's station on the other unit, switching the video feed back and forth between the units in order to cover both units. Only having 4 staff on the 2 units did not allow for a safe management of the patient. An interview with RN-A on 7/12/12 at 10:45 AM confirmed the facility was still in the practice of staffing with only 4 staff when the census was down on the BHS units. RN-A also confirmed their security officers were off-duty law enforcement and were not trained on how to assist with restraint or seclusion of patients and did not have CPI (Crisis Prevention Intervention) training.

According to the medical record for Patient 1, at the end of the night shift on 5/17/12, Patient 1 had been pacing the hallway, talking, yelling, flipping on the lights to other patient rooms, and behaving in an agitated, non-redirectable manner. Review of the video feed for the facility self-reported incident that occurred on 5/17/12 at 6:27 AM showed the charge nurse, RN-B walking at a fast pace across the screen towards Patient 1 who was standing near the phone across from the nurse's station. RN-B grabbed Patient 1 by the upper arms, turned the patient forcibly around still holding the patient's upper arms and progressed to push the patient down the hallway and out of view. RN-B did not follow the policy and procedure to lead a team to manage the patient. Review of pictures taken by the facility following the report of abuse on 5/23/12 showed the patient had bruises on the upper arms consistent with hand/finger marks from the method used by RN-B. According to the facility internal investigation RN-B did not do a debriefing following the incident with the 2 other staff that came to assist RN-B after the patient was already in the patient's own room. The other staff working that night did not report the incident until 5/23/12, 6 days after the incident occurred when they worked together and learned of Patient 1's bruising. This allowed the patients on IPC and PPC units to remain at risk for abuse for 6 additional days.

Review of the facility internal investigation found RN-B was no longer employed by the facility. The facility had the other staff on the BHS units review the policy and procedure on abuse and abuse reporting. The facility did not do any training to ensure the staff were knowledgeable on the restraint policy and procedure that directs that the RN leads a team of trained staff to take control of a patient when they are a danger to themselves or others using the proper method of hands on approach, and that a debriefing be held after the restraint/seclusion incident to determine if the patient or any of the staff were injured; if anything else could have been done to prevent the need for restraint and seclusion; and to decide if there needs to be changes made to the treatment/care plan or to the medication regimen as per facility policy and procedure "Dr. Strong ORG 9.405" last revised 7/2010.

After collaboration with Centers for Medicare and Medicaid Services (CMS), Immediate Jeopardy conditions were determined to exist. The facility administrator was informed of an Immediate Jeopardy (IJ) situation on 7/12/12 at 4:15 PM. The facility was requested to put in place the actions that would abate the immediate jeopardy status. The facility completed 3 tasks to abate the IJ that included:
1. Arranging for the training of the security staff working at the psychiatric unit campus in the application of restraints and assisting staff with taking a patient to a restraint or seclusion room. The training was started prior to the night shift and all security staff would be trained prior to their working their shift.
2. Arranging the staffing for the night shift to show a minimum of 6 staff, including the trained security officer was scheduled for each shift from that night forward. Schedule of staffing for the rest of July and for the month of August were provided.
3. Just in Time training of all the behavioral health staff on the policy and procedure for restraint and seclusion, and use of a debriefing form after each and every restraint/seclusion episode. Staff would receive this training along with competency testing prior to working their shift beginning with the night shift on 7/12/12.

Based on the documentation provided by the facility regarding the 3 tasks identified above, the IJ was abated on 7/12/12 at 7:10 PM. Refer to the deficiency statements at A-0142, A-0144 and A-0145 for additional details.
VIOLATION: PATIENT RIGHTS: PRIVACY AND SAFETY Tag No: A0142
Based on observation, medical record reviews, staff interviews, review of the facility internal investigation, review of the video record from the Intensive Psychiatric Care (IPC) unit, and review of the facility's policies and procedures, the facility failed to provide patient care in a safe setting. This failure resulted in finding the Standard of Privacy and Safety out of compliance. In a sample of 10 patients, 5 patients were selected from the psychiatric programs. Sampled Patient 1 suffered injury because the facility failed to ensure adequate numbers of trained staff were available at all times to meet the needs of psychiatric patients on the Behavioral Health Services (BHS) units. This resulted in an insufficient number of staff available to safely handle a psychiatric emergency situation that occurred at 6:27 AM on 5/17/12 when Patient 1 was agitated, and manic, with the risk of losing self-control. The facility also failed to ensure sampled Patient 1 was protected from staff abuse, and failed to ensure that staff present at that time reported the abuse within the 24 hour time frame as directed in facility policy and procedure leaving patients at continued risk for abuse. The Facility census on the day of entrance was 52 including 16 patients on the 2 Behavioral Health Services units housed in a building on a separate campus. Findings are:

Tour on 7/11/12 beginning at 3:35 PM on the psychiatric programs BHS units (housed on a separate campus approximately 1 mile away from the main campus) found there were 2 units, the IPC unit and the Progressive Psychiatric Care unit (PPC). The IPC unit accepts patients that are admitted under an Emergency Protective Custody (EPC) order. According to the Director of Behavioral Health during the night shift the building is empty of employees except for the nursing staff on IPC and PPC along with 1 security officer in the building. In an interview with the Director of Behavioral Health on 7/11/12 during the tour, it was determined that the security staff had not been trained in psychiatric restraint application or assisting staff with the hands on placing of an out-of-control patient in seclusion or restraint. It was also revealed that the staffing for the night shift (6:45 PM to 7:15 AM) is based on census of the units resulting in some night shifts with just 4 nursing staff that would include 1 Registered Nurse (RN), another RN or Licensed Practical Nurse (LPN), and 2 Behavioral Techs to cover both units. During the night shift ending at 7:15 AM on 5/17/12, the facility had staffed the 2 units with a total of 4 staff (1 RN, 1 LPN, and 2 Behavioral Techs). To safely attend to an out-of-control patient, acceptable standard of practice, requires 5 staff members (1 trained RN to direct the staff and the patient, and 4 other trained staff, with each staff assigned to an extremity). In addition, 1 staff is needed on each unit to monitor and watch the other patients. During the tour it was found that the facility did have video cameras on both units, potentially allowing 1 staff member to watch the monitor from the nurse's station on the other unit, switching the video feed back and forth between the units in order to cover the monitoring of both units. Only having 4 staff on the 2 units did not allow for a safe management of patients that had become a danger to themselves or others. An interview with RN-A on 7/12/12 at 10:45 AM confirmed the facility was still in the practice of staffing with only 4 staff when the census was down on the BHS units. On the night shift ending at 7:15 AM on 5/17/12 the census was 6 patients on IPC including Patient 1 and 4 patients on PPC for a total census of 10. RN-A also confirmed their security officers were off-duty law enforcement and were not trained on how to assist with restraint or seclusion of patients. When they are called to assist they expect the security officer to help keep an eye on other patients or what ever the charge nurse directs them to do, but not to have hands on with a patient that is out of control.

According to review of the medical record for Patient 1, at the end of the night shift on 5/17/17, Patient 1 had been pacing the hallway, talking, yelling, flipping on the lights to other patient rooms, and behaving in an agitated, non-redirectable manner. Review of the video feed for the facility self-reported incident that occurred on 5/17/12 at 6:27 AM showed the charge nurse, RN-B walking alone at a fast pace across the screen towards Patient 1 who was standing near the phone across from the nurse's station. RN-B grabbed Patient 1 by the upper arms turned the patient forcibly around still holding the patients's upper arms and progressed to push the patient down the hallway and out of view. RN-B did not follow the policy and procedure to lead a team to manage the patient. Review of pictures taken by the facility following the report of abuse on 5/23/12 showed the patient had bruises on the upper arms consistent with hand/finger marks from the method used by RN-B. According to the facility internal investigation RN-B did not do a debriefing following the incident with the 2 other staff that came to assist RN-B after the patient was already in the patient's own room. The other staff working that night did not report the incident until 5/23/12, 6 days after the incident occurred when they worked together again and learned of Patient 1's bruising. This allowed the patients on IPC and PPC units to remain at risk for abuse for 6 additional days.

After consultation with the Centers for Medicare and Medicaid Services (CMS) on 7/12/12, an Immediate Jeopardy [IJ] situation was determined to exist based on risk to patient safety secondary to the possibility of inadequate numbers of trained staffing on the night shift to handle psychiatric/behavioral emergencies, and the risk of abuse to behavioral health patients since the facility did not ensure staff on the behavioral health units were knowledgeable on the safe use of restraint/seclusion and debriefing following a violent patient behavior episode. The Administrator and other facility management staff were informed of the IJ on 7/12/12 at 4:15 PM. The facility was directed to put into place actions that would abate the IJ situation. Based on the documentation the facility provided the IJ was abated at 7:10 PM on 7/12/12.
Refer to deficiency statements at A-0144 and A-0145 for additional details.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on observation, medical record reviews, staff interviews, review of the facility internal investigation, review of the video record from the Intensive Psychiatric Care (IPC) unit, and review of the facility's policies and procedures, the facility failed to provide patient care in a safe setting for 1 of 5 sampled patients from the Behavioral Health Services (BHS) program (Patient 1)]. The total sample was 10 patients. On the day of entrance the facility census was 52 including 16 patients from the BHS program housed on a separate campus approximately 1 mile away from the main hospital campus. Findings are:

The facility self-reported an incident of staff to patient abuse that occurred on 5/17/12 at 6:27 AM on the IPC unit in their BHS. The facility does accept Emergency Protective Custody (EPC) order patients on the IPC unit. EPC is implemented by a law enforcement officer to involuntarily admit a patient who is a danger to themselves or to others. The patient in the facility self-report was selected to be on the sample as Patient 1. Review of the medical record for Patient 1 revealed the patient had been admitted to IPC unit on 5/14/12 on a EPC order following some bizarre and aberrant behavior. Patient 1 had diagnoses identified in the History and Physical dated 5/15/12 of bipolar with psychotic features, history of substance abuse, personality disorder, and severe interpersonal problems. According to Physician Progress notes beginning on 5/15 through 5/18/12, Patient 1 was very manic and delusional with racing thoughts, inability to sleep, mood swings, and agitation. Patient 1 also had a history of adverse reactions to some of the medications that the patient had taken in the past that included reactions of cardiac changes and arrythmias that required caution in prescribing medications to treat the patient's psychiatric conditions. The Physician noted in the Progress Notes on 5/17/12 following the reported incident that Patient 1 had been agitated the previous night getting worse and worse as the night went on. The physician stated this was possibly due to an idiopathic reaction to Ambien (a sleeping medication) given to the patient at 1:05 AM on 5/17/12. The documentation in the patient's record related to the night shift ending at 7:15 AM on 5/17/12 noted that the patient had been pacing the halls, yelling, turning on and off the lights in other patient rooms, not redirecting, and not staying in the patient's own room.

Review of the video record from the IPC unit on 5/17/12 during the time frame of the facility reported incident of staff to patient abuse beginning at 6:27 AM, showed RN-B coming into camera view from the left side (where the nurse's station is located). RN-B was walking at a fast pace towards the patient. Patient 1 was standing across from the nurse's station by the patient phone looking towards the nurse's station. RN-B came up to Patient 1 and grabbed both upper arms, twisted the patient around, still holding onto the patient and forcibly pushed the patient down the hall and out of the sight of the camera. The patient was not acting aggressively towards RN-B until after RN-B grabbed the patient's arms and started to forcibly turn the patient around. Within a short time the video shows another female staff member and then a male staff member walking quickly down the hallway in the direction RN-B had pushed Patient 1. The video did not have any audio, so it was not possibly to determine what might have been said by any of the parties on camera.

Review of the facility investigation documentation revealed that the patient had been pushed to the patient's own room, and when the 2 other staff arrived in the patient's room the patient was on the bed crying. The 2 additional staff then assisted RN-B to get control of the patient. While this was happening, the remaining staff member. a Licensed Practical Nurse (LPN) in the nursing station of the other behavioral health unit, the Progressive Psychiatric Care (PPC) unit was watching the television monitor to cover for both units. The LPN called a Dr. Strong (a policy and procedure identified name to obtain more help in a psychiatric emergency). This action will notify the security officer to come to the unit to assist the staff. The security officer on duty responded to the unit and went to Patient 1's room and stood by to assist as directed by the unit staff. The patient was walked to the seclusion room with a staff member on each side of the patient holding an arm. Patient 1 was placed in locked seclusion. RN-B completed the documentation, but did not talk with the other staff involved in the incident. All left at the end of the shift (about 7:15 AM). According to the facility investigation, the next time the staff that worked that night worked together was 5/23/12. When they talked to each other about what had happened the night of 5/17/12 and realized the patient had bruises from the incident, they decided they needed to report it. They did report it on 5/23/12 to the Director of Behavioral Health. The facility initiated an investigation immediately, resulting in the termination of RN-B. The facility then required the BHS staff to review/read the policy on abuse and abuse reporting. The facility reported the abuse to law enforcement, adult protective services, and occupational licensure.

On 7/10/12 at 6:30 PM an interview was held with one of the Behavioral Health Techs (BHT-C) that worked the 5/17/12 shift when the incident occurred. BHT-C revealed Patient 1 had been having a "difficult night" without sleeping, getting up and down, flicking lights on and off in other patient rooms, giving staff the finger, knocking on the nurse's station door, saying wanted a cigarette and wanted to go home. The patient was very "labile," laughing, then crying, then angry. BHT-C said there were only 2 staff on the IPC, including RN-B and BHT-C. Both BHT-C and RN-B were in the nurse's station. BHT-C had to watch the monitor of the hallway and the patient rooms (they had 6 patients on the unit that night including Patient 1). BHT-C said they left Patient 1 alone if the patient was not bothering anyone. They allowed her to roam the hallway. BHT-C said RN-B had not spent much time out on the unit with the patients during the night. BHT-C revealed RN-B was at the computer and BHT-C was watching down the hallway and at the monitor of the patient's rooms. Patient 1 came towards the nurse's station with a plastic water container. BHT-C added that when the patient got close to the station, BHT-C opened the door and Patient 1 looked like she was going to throw the plastic water glass at her. BHT-C said she told the patient "don't hit me with that" and she took the water glass away from the patient. The patient then threw the plastic lid at BHT-C. BHT-C said she closed the station door. Then RN-B asked what had happened and BHT-C told him Patient 1 had thrown the plastic water glass lid at her. RN-B then got up from the computer and rushed out of the station at the patient. BHT-C said she turned away from the door and the monitor to call for assistance from the other unit. The other unit had seen something was happening on their monitor and the other BHT (BHT-D) was on the way over. When BHT-C turned around RN-B was already pushing Patient 1 into the patient's own room. By the time the 2 BHTs entered the patient's room the patient was on the bed crying. At this time BHT-C said the patient was fighting RN-B and crying. BHT-C and BHT-D assisted to get the patient under control. BHT-D told BHT-C to push the panic button to signal for more help which BHT-C did, so more help would come; however, the only other staff in the building was the LPN who would need to stay on the other unit to monitor those patients and a security officer. BHT-C said the security officer for the building arrived and stood in the room, but did not actually have any hands on the patient. They were able to get Patient 1 to cooperate with the walk down the hallway to the seclusion room. Patient 1 was placed in locked seclusion, then BHT-C said they all returned to their own work, and RN-B had to give report for the on-coming day shift. They did not have a debriefing and they all left at the end of the shift. None of the staff working with RN-B that night saw the whole event. BHT-C said they did not work together again until 5/23/12. When they worked together that night they talked about what had happened, knew the patient had bruises from the incident and decided they needed to report the incident because RN-B had not followed the facility's policy on leading a team and to never deal with a patient or take a patient on in a situation like that alone. They reported it when the Director of Behavioral Health came on the unit at the end of their shift.

An interview with the LPN working that night (LPN-E) was completed on 7/11/12 at 9:00 AM. LPN-E revealed that she had been the charge nurse on the PPC unit and RN-B had been charge on IPC unit. Each unit had 1 BHT working for a total of 2. They knew that IPC had a couple of patients that were exhibiting behaviors during the night. They were ready to help if needed and they let them know that on IPC. LPN-E added that if they had a low census, there would only be 4 nursing staff to cover the night shift. LPN-E said on 5/17/12 about 6:00 AM there was increased activity on the IPC unit. They have a monitor in the nurse's station on PPC that they can switch to view the camera feeds on the IPC unit. They were watching the monitor of what was going on over on the IPC unit when they saw Patient 1 walk towards the nurse's station and then walk away. Then they saw RN-B come out of the nurse's station into view of the camera and put his hands on Patient 1. LPN-E said she sent BHT-D over to help and then called security to come to help. She got a call from BHT-C and told her that BHT-D was on the way to help. Watching the monitor LPN-E watched RN-B push Patient 1 down the hall and into the patient's own room. In the room, she watched RN-B shove Patient 1 down on the bed. At that point BHT-C and BHT-D came into the room. BHT-C took the patient's legs and pushed the panic button, and BHT-D helped RN-B take control of the upper extremities. LPN-E then said she watched RN-B, BHT-C, BHT-D and Security walk Patient 1 to the seclusion room with hands on the patient. The patient appeared to be cooperating at that time. LPN-E took the blame for not reporting the abuse the morning that it happened with the excuse that she only saw it on camera and did not talk with the other staff until they worked together again on 5/23/12. They talked about what happened and knew they needed to report it.

An interview was completed with BHT-D on 7/11/12 at 12 noon. BHT-D revealed they had been watching the IPC unit on their monitor because there had been behavior's going on that unit. When they saw RN-B going from the nurse's station and pushing Patient 1 ahead of him down the hall, BHT-D immediately went to help. BHT-D said he and BHT-C entered the patient's room and the patient was already lying on the bed, crying and struggling. BHT-D said he told BHT-C to push the panic button which she did. BHT-D went to assist with the upper extremity and BHT-C tried to control the patient's legs which BHT-D said is very hard for 1 person to do alone. BHT-D said he was on the patient's left side holding the patient's arm with one hand above and the other hand below the elbow. BHT-D saw that RN-B had the patient's right arm pulled up with the elbow bent and above and behind the patient's head. BHT-D knew this was an inappropriate method to hold the patient's extremity, and told RN-B to take the patient's arm and hold it down to the side, above and below the elbow like he was doing. BHT-D said RN-B then changed the arm position as directed. Then BHT-D asked RN-B "What do you want to do?" RN-B directed they would take Patient 1 to seclusion. BHT-D said he asked the patient to cooperate so it would be easier on the patient. (Note this was not coming from the RN that is supposed to be the trained person in charge of this kind of situation). BHT-D said Patient 1 was cooperative going to seclusion and all they had to do was hold the arms loosely. Then BHT-D returned to the PPC unit, finished charting and left at the end of the shift. BHT-D indicated that usually they have a debriefing following a restraint/seclusion episode, but they did not that day. Normally the RN is the one who leads and also holds the debriefing, but RN-B didn't do that. BHT-D said during the episode Patient 1 didn't say anything but was crying. He felt "bad" for the patient. He said he did not actually see RN-B grab the patient as he was already on the way over to help but he thought RN-B seemed "angry". The next time he worked with the LPN-E and BHT-C they talked about what happened and put all their stories together, they also knew Patient 1 had bruises from the incident and they knew they needed to report it. They went to the Director of Behavior Health with their report when the Director came in on the morning of 5/23/12.

An interview with clinical manager of behavioral health, RN-A completed on 7/12/12 at 10:45 AM revealed the staffing on the BHS units is based on the census and there are night shifts when there are only 4 nursing staff on duty. They also have off-duty law enforcement working as security officers (there would be 1 on duty during the night shift), but they have not had CPI training (Crisis Prevention Intervention), and they have not had training on the methods of safely assisting with hands on placing a patient in seclusion or restraint.

Review of Internet articles related to the management of aggressive and violent behavior in the psychiatric setting found an article on Nursing Management of Aggression updated on 1/22/11 under the Psychiatric Nursing website, www.nursingplanet.com/pn/nursing_management_aggression.html. The article discusses the nursing process in the clinical management of the psychiatric crisis situation. It states that "Effective crisis management must be organized and should be directed by one clearly identified crisis leader." "Assemble a crisis team. Devise a plan to manage crisis and inform team. Assign securing pf patient's limbs to crisis team members. Explain necessity of intervention to patient and attempt to enlist cooperation. Restrain patient when decided by the crisis leader. Maintain calm consistent approach to patient. Review crisis management interventions with crisis team." Another web site article titled Managing the Aggressive and Violent Patient in the Psychiatric Emergency can be found at www.sciencedirect.com. The article was accepted in January 2006. It states if all less restrictive interventions have been ineffective, it could be necessary to use restraint or seclusion. "This comports [leads to] the actuation of risky procedures that have to be done properly by well trained and experienced staff to avoid physical and psychological traumas or even death. It is crucial to have enough people to do the last attempt of show of force and to act the intervention in the safest and quickest way. It is suggested a minimum of 5 staff members." When the decision has been made by the staff leader that the patient requires seclusion or restraint, the leader should perform a short briefing to define details and roles of the staff members on the team. At this point generally it is too late for any negotiation with the patient; however, the patient should be informed on what is going to happen and asked to cooperate. This article indicates the minimum number of staff to safely take control of an aggressive patient that is out of control to seclusion or to place in restraints is 5. This includes a leader, and at least 1 staff member that can be assigned to safely secure each limb of the patient.

The facility failed to ensure adequate numbers of trained staff were being scheduled on the BHS units on all the night shifts to provide care in a safe environment that resulted in staff abuse with injury to a patient. The facility failed to recognize the issue of staffing needs following this incident that allowed the continuation of night shifts which failed to have adequate numbers of trained staff to ensure provision of care in a safe setting for the patients on the BHS units.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on observation, medical record reviews, staff interviews, review of the facility internal investigation, review of the video record from the Intensive Psychiatric Care (IPC) unit, and review of the facility's policies and procedures, the facility failed to protect patients from staff abuse for 1 of 5 sampled patients from the Behavioral Health Services (BHS) program (Patient 1). The total sample was 10 patients. On the day of entrance the facility census was 52 including 16 patients from the BHS program housed on a separate campus approximately 1 mile away from the main hospital campus. Findings are:

The facility self-reported an incident of staff to patient abuse that occurred on 5/17/12 at 6:27 AM on the IPC unit in their BHS. The patient in the facility self-report was selected to be on the sample as Patient 1. Review of the medical record for Patient 1 revealed the patient had been admitted on [DATE] on an Emergency Protective Custody (EPC) order, an involuntary admission, following some bizarre and aberrant behavior in the community. Patient 1 had diagnoses identified in the History and Physical dated 5/15/12 of bipolar with psychotic features, history of substance abuse, personality disorder, and severe interpersonal problems. According to Physician Progress notes beginning on 5/15 through 5/18/12, Patient 1 was very manic and delusional with racing thoughts, inability to sleep, mood swings, and agitation. Patient 1 also had a history of adverse reactions to some of the medications that the patient had taken in the past that included reactions of cardiac changes and arrythmias that required caution in prescribing medications to treat the psychiatric conditions. The Physician noted in the Progress Notes on 5/17/12 following the reported incident that Patient 1 had been agitated the previous night getting worse and worse as the night went on. The physician stated this was possibly due to an idiopathic reaction to Ambien (a sleeping medication) given to the patient at 1:05 AM on 5/17/12. The documentation in the patient's record related to the night shift ending at 7:15 AM on 5/17/12 noted that the patient had been pacing the halls, yelling, turning on and off the lights in other patient rooms, not redirecting, and not staying in the patient's own room. The physician was not called during the night to report the patient's escalating agitation and disruption on the unit.

Review of the video record from the IPC unit on 5/17/12 during the time frame of the facility reported incident of staff to patient abuse that began at 6:27 AM, showed Registered Nurse (RN-B) coming into camera view from the left side (where the nurse's station is located). RN-B was walking at a fast pace towards the patient. Patient 1 was standing across from the nurse's station by the unit's patient phone looking towards the nurse's station. RN-B came rushed up to Patient 1 and grabbed both upper arms, twisted the patient around, still holding onto the patient and forcibly pushed the patient down the hall and out of the sight of the camera. The patient was not acting aggressively towards RN-B until after RN-B grabbed the patient's arms and started to forcibly turn the patient around. Within a short time the video shows another female staff member and then a male staff member walking quickly down the hallway in the direction RN-B had pushed Patient 1. The video did not have any audio, so it was not possibly to determine what might have been said by any of the parties on camera.

Review of the facility investigation documentation revealed that the patient had been pushed to the patient's own room, and when the 2 other staff arrived in the patient's room the patient was lying on her back on the bed crying. The 2 additional staff then assisted RN-B to gain control of the patient who was struggling with RN-B. While this was happening, the remaining staff member. a Licensed Practical Nurse (LPN])in the nursing station of the Progressive Psychiatric Care unit (PPC) was watching the television monitor to cover for both units. The LPN called a Dr. Strong (a policy and procedure identified name to obtain more help in a psychiatric emergency). This action will notify the security officer to come to the unit to assist the staff and other staff in the building during the day shift when additional employees are present elsewhere on the campus. The security officer on duty responded to the unit and went to Patient 1's room and stood by to assist as directed by the unit staff. The patient was walked to the seclusion room with a staff member on each side of the patient holding an arm. Patient 1 was placed in locked seclusion. RN-B completed the documentation, but did not talk with the other staff involved in the incident. All left at the end of the shift (about 7:15 AM). According to the facility investigation, the next time the staff that worked that night worked together was 5/23/12. When they talked to each other about what had happened the night of 5/17/12 and realized the patient had bruises from the incident, they decided they needed to report it. They did report it on 5/23/12 to the Director of Behavioral Health. The facility initiated an investigation immediately, resulting in the termination of RN-B. The facility then required the BHS staff to review/read the policy on abuse and abuse reporting. The facility reported the abuse to law enforcement, adult protective services, and occupational licensure.

On 7/10/12 at 6:30 PM an interview was held with one of the Behavioral Health Techs (BHT-C) that worked the 5/17/12 shift when the incident occurred. BHT-C revealed Patient 1 had been having a "difficult night" without sleeping, getting up and down, flicking lights on and off in other patient rooms, giving staff the finger, knocking on the nurse's station door, saying wanted a cigarette and wanted to go home. The patient was very "labile," laughing, then crying, then angry. BHT-C said there were only 2 staff on the IPC, including RN-B and BHT-C. Both BHT-C and RN-B were in the nurse's station. BHT-C had to watch the monitor of the hallway and the patient rooms (they had 6 patients on the unit that night including Patient 1). BHT-C said they left Patient 1 alone if the patient was not bothering anyone. They allowed the patient to roam the hallway. RN-B did not spend much time out on the unit. BHT-C revealed RN-B was at the computer, BHT-C was watching down the hallway and at the monitor of the patient's rooms. Towards the end of the shift Patient 1 came towards the nurse's station with a plastic water container. BHT-C added that when the patient got close to the station, BHT-C opened the door and Patient 1 looked like she was going to throw the plastic water glass at her. BHT-C said she told the patient "don't hit me with that" and then took the water glass away from the patient. The patient then threw the plastic lid at BHT-C. BHT-C said she closed the station door. Then RN-B asked what had happened and BHT told him Patient 1 had thrown the plastic water glass lid at her. RN-B then got up from the computer and rushed out of the station at the patient. BHT-C said she turned away from the door and the monitor to use the phone to call for assistance from the other unit. The staff on the other unit had seen something was happening on their monitor and the other BHT (BHT-D) was on the way over. When BHT-C turned back around RN-B was already pushing Patient 1 into the patient's own room. By the time the 2 BHT's entered the patient's room the patient was on the bed crying. At this time BHT-C said the patient was fighting RN-B and crying. BHT-C and BHT-D assisted to get the patient under control. BHT-D told BHT-C to push the panic button to signal for more help which BHT-C did, so more help would come; however, the only other staff in the building was the LPN who would need to stay on the other unit to monitor those patients and a security officer. BHT-C said the security officer for the building arrived and stood in the room, but did not actually have any hands on the patient. They were able to get Patient 1 to cooperate with the walk down the hallway to the seclusion room. Patient 1 was placed in locked seclusion, then BHT-C said they all returned to their own work, and RN-B had to give report for the on-coming day shift. They did not have a debriefing and they all left at the end of the shift. BHT-C said none of the staff working with RN-B that night saw the whole event. BHT-C said they did not work together again until 5/23/12. When they worked together on that night they talked about what had happened, knew the patient had bruises from the incident and decided they needed to report the incident because RN-B had not followed the facility's policy on leading a team and to never deal with a patient or take a patient on in a situation like that alone. They reported it when the Director of Behavioral Health came on the unit at the end of their shift.

An interview with the LPN working that night (LPN-E) was completed on 7/11/12 at 9:00 AM. LPN-E revealed that she had been the charge nurse on the PPC unit and RN-B had been charge on IPC unit. Each unit had 1 BHT working for a total of 2. That meant they had a total of 4 staff to cover the 2 units. They knew that IPC had a couple of patients that were exhibiting behaviors during the night. They were ready to help if needed and LPN-E said they had let them know that on IPC. LPN-E added that if they had a low census, there would only be 4 nursing staff to cover the night shift. LPN-E said on 5/17/12 about 6:00 AM there was increased activity on the IPC unit. They have a monitor in their nurse's station on PPC that they can switch to view the camera feeds on the IPC unit. They were watching the monitor of what was going on over on the IPC unit when they saw Patient 1 walk towards the nurse's station and then walk away. Then they saw RN-B come out of the nurse's station into view of the camera and put his hands on Patient 1. LPN-E said she sent BHT-D over to help and then called security to come to help. She got a call from BHT-C and told her that BHT-D was on the way to help. Watching the monitor LPN-E watched RN-B push Patient 1 down the hall and into the patient's own room. In the room, she watched on the camera feed RN-B shove Patient 1 down on the bed. At that point BHT-C and BHT-D came into the room. BHT-C took the patient's legs and pushed the panic button, and BHT-D helped RN-B take control of the upper extremities. LPN-E then said she watched RN-B, BHT-C, BHT-D and Security walk Patient 1 to the seclusion room with hands on the patient. The patient appeared to be cooperating at that time. LPN-E took the blame for not reporting the abuse the morning that it happened with the excuse that she only saw it on camera and did not talk with the other staff until they worked together again on 5/23/12. They talked about what happened and knew they needed to report it.

An interview was completed with BHT-D on 7/11/12 at 12 noon. BHT-D revealed they had been watching the IPC unit on their monitor because there had been behaviors going on during the night. When they saw RN-B going from the nurse's station and pushing Patient 1 ahead of him down the hall, BHT-D immediately went to help. BHT-D said he and BHT-C entered the patient's room and the patient was already lying on the bed, crying and struggling. BHT-D said he told BHT-C to push the panic button which she did. BHT-D went to assist with the upper extremity and BHT-C tried to control the patient's legs which BHT-D said is very hard for 1 person to do alone. BHT-D said he was on the patient's left side holding the patient's arm with one hand above and the other hand below the elbow. BHT-D saw that RN-B had the patient's right arm pulled up with the elbow bent and above and behind the patient's head. BHT-D knew this was an inappropriate position to hold the arm, and told RN-B to take the patient's arm and bring it down to the side, and hold above and below the elbow like he was doing. BHT-D said RN-B then changed the arm position as directed. Then BHT-D asked RN-B "What do you want to do?" RN-B directed they would take Patient 1 to seclusion. BHT-D said he asked the patient to cooperate so it would be easier on the patient. (Note this was not coming from the RN that is supposed to be the trained person in charge of this kind of situation). BHT-D said Patient 1 was cooperative going to seclusion and all they had to do was hold the arms loosely. Then BHT-D returned to the PPC unit, finished charting and left at the end of the shift. BHT-D indicated that usually they have a debriefing following a restraint/seclusion episode, but they did not that day. Normally the RN is the one who leads and also holds the debriefing, but RN-B didn't do that. BHT-D said during the episode Patient 1 didn't say anything but was crying. He felt "bad" for the patient. He said he did not actually see RN-B grab the patient as he was already on the way over to help but he thought RN-B seemed angry. The next time he worked with LPN-E and BHT-C they talked about what happened and put all their stories together, they also knew Patient 1 had bruises from the incident and they knew they needed to report it. They went to the Director of Behavior Health with their report when the Director came in on the morning of 5/23/12.

According to the facility investigation report the facility addressed this incident by having the staff employed on the BHS units read the policy and procedure on abuse and abuse reporting. Interviews with the Director of Behavioral Health, on 7/11/12 beginning at 9:00 AM and throughout the day confirmed they did not have a competency test following reading of the policy. The facility did not retrain and competency test the staff on use of seclusion/restraint or review of the CPI (Crisis Prevention Intervention) training that all employees in behavioral health services are required to have. The facility also did not provide CPI training or training on assisting with seclusion/restraint for the security officers that may need to be called upon to assist in a psychiatric emergency situation. This failure placed patients at risk for additional staff abuse and injury.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0167
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on observation, medical record reviews, staff interviews, review of the facility internal investigation, review of the video record from the Intensive Psychiatric Care (IPC) unit, and review of the facility's policies and procedures, the facility failed to ensure staff followed safe and appropriate techniques for management of patient behaviors for 1 of 5 sampled patients from the Behavioral Health Services (BHS) program (Patient 1). The total sample was 10 patients. On the day of entrance the facility census was 52 including 16 patients from the BHS program housed on a separate campus approximately 1 mile away from the main hospital campus. Findings are:

The facility self-reported an incident of staff to patient abuse that occurred on 5/17/12 at 6:27 AM on the IPC unit in their BHS. The patient in the facility self-report was selected to be on the sample as Patient 1. Review of the medical record for Patient 1 revealed the patient had been admitted on [DATE] following some bizarre and aberrant behavior in the community. The patient was an EPC (Emergency Protective Custody) admission. Patient 1 had diagnoses identified in the History and Physical dated 5/15/12 of bipolar with psychotic features, history of substance abuse, personality disorder, and severe interpersonal problems. According to Physician Progress notes beginning on 5/15 through 5/18/12, Patient 1 was very manic and delusional with racing thoughts, inability to sleep, mood swings, and agitation. Patient 1 also had a history of adverse reactions to some of the medications that the patient had taken in the past that included reactions of cardiac changes and arrythmias that required caution in prescribing medications to treat the psychiatric conditions. The Physician noted in the Progress Notes on 5/17/12 following the reported incident that Patient 1 had been agitated the previous night getting worse and worse as the night went on. The physician stated this was possibly due to an idiopathic reaction to Ambien (a sleeping medication) given to the patient at 1:05 AM on 5/17/12. The documentation in the patient's record related to the night shift ending at 7:15 AM on 5/17/12 noted that the patient had been pacing the halls, yelling, turning on and off the lights in other patient rooms, not redirecting, and not staying in the patient's own room. The physician was not called during the night to report the patient's escalating agitation and disruption on the unit.

Review of the video record from the IPC unit on 5/17/12 during the time frame of the facility reported incident of staff to patient abuse that began at 6:27 AM, initially showed the patient walking towards the left side of the screen where the nurse's station is located and then walking back to an area with tables, chairs, a phone for patient use. Patient 1 was not acting in an aggressive or destructive manner. Next the video showed RN-B coming into camera view from the left side (where the nurse's station is located). RN-B was walking at a fast pace towards the patient. Patient 1 was still standing across from the nurse's station by the patient phone looking towards the nurse's station. RN-B rushed up to Patient 1 and grabbed both upper arms, twisted the patient around, still holding onto the patient and forcibly pushed the patient down the hall and out of the sight of the camera. The patient was not acting aggressively towards RN-B until after RN-B grabbed the patient's arms and started to forcibly turn the patient around. Within a short time the video shows another female staff member and then a male staff member walking quickly down the hallway in the direction RN-B had pushed Patient 1. The video did not have any audio, so it was not possibly to determine what might have been said by any of the parties on camera.

Review of the facility investigation documentation revealed that the patient had been pushed to the patient's own room, and when the 2 other staff arrived in the patient's room the patient was lying on her back on the bed crying. The 2 additional staff then assisted RN-B to gain control of the patient who was struggling with RN-B. While this was happening, the remaining staff member, a Licensed Practical Nurse (LPN) in the nursing station of the Progressive Psychiatric Care unit (PPC) was watching the television monitor to cover for both units. The LPN called a Dr. Strong (a policy and procedure identified name to obtain more help in a psychiatric emergency). This action will notify the security officer to come to the unit to assist the staff and other staff in the building during the day shift when additional employees are present elsewhere on the campus. The security officer on duty responded to the unit and went to Patient 1's room and stood by to assist as directed by the unit staff. The patient was walked to the seclusion room with a staff member on each side of the patient holding an arm. Patient 1 was placed in locked seclusion. RN-B completed the documentation, but did not talk with the other staff involved in the incident. All left at the end of the shift (about 7:15 AM). According to the facility investigation, the next time the staff that worked that night worked together was 5/23/12. When they talked to each other about what had happened the night of 5/17/12 and realized the patient had bruises from the incident, they decided they needed to report it. They did report it on 5/23/12 to the Director of Behavioral Health. The facility initiated an investigation immediately, resulting in the termination of RN-B. The facility then required the BHS staff to review/read the policy on abuse and abuse reporting. The facility reported the abuse to law enforcement, adult protective services, and occupational licensure. The facility did not require BHS staff to review their CPI (Crisis Prevention Intervention) training or the policy and procedure on use of restraint and seclusion. The facility did not do competency testing on any policy and procedure or behavior management techniques.

On 7/10/12 at 6:30 PM an interview was held with one of the Behavioral Health Techs (BHT-C) that worked the 5/17/12 shift when the incident occurred. BHT-C revealed Patient 1 had been having a "difficult night" without sleeping, getting up and down, flicking lights on and off in other patient rooms, giving staff the finger, knocking on the nurse's station door, saying wanted a cigarette and wanted to go home. The patient was very "labile," laughing, then crying, then angry. BHT-C said there were only 2 staff members working on the IPC unit that included RN-B and BHT-C. Both BHT-C and RN-B were in the nurse's station prior to the incident. BHT-C had to watch the monitor of the hallway and the patient rooms which all had cameras in them (they had 6 patients on the unit that night including Patient 1). BHT-C said they left Patient 1 alone if the patient was not bothering anyone. They allowed the patient to roam the hallway during the night. BHT-C indicated RN-B did not normally spend much time out on the unit. BHT-C revealed while RN-B was at the computer, BHT-C was watching down the hallway and at the monitor of the patient's rooms. Towards the end of the shift Patient 1 came towards the nurse's station with a plastic water container. BHT-C added that when the patient got close to the station, BHT-C opened the door and Patient 1 looked like she was going to throw the plastic water glass at her. BHT-C said she told the patient "don't hit me with that" and then took the water glass away from the patient. The patient then threw the plastic lid at BHT-C. BHT-C said she closed the station door. Then RN-B asked what had happened and BHT told him Patient 1 had thrown the plastic water glass lid at her. RN-B then got up from the computer and rushed out of the station at the patient.

An interview was completed with BHT-D on 7/11/12 at 12 noon. BHT-D revealed they had been watching the IPC unit on their monitor during the night of 5/16-17/12 because there had been behaviors going on during the night. When they saw RN-B going from the nurse's station and pushing Patient 1 ahead of him down the hall, BHT-D immediately went to help. BHT-D said he and BHT-C entered the patient's room and the patient was already lying on the bed, crying and struggling. BHT-D said he told BHT-C to push the panic button which she did. BHT-D went to assist with the left upper extremity and BHT-C tried to control the patient's legs which BHT-D said is very hard for 1 person to do alone and can lead to staff or patient injury. BHT-D said he was on the patient's left side holding the patient's left arm with one hand above and the other hand below the elbow as trained. BHT-D saw that RN-B had the patient's right arm pulled up with the elbow bent and above and behind the patient's head. BHT-D knew this was an inappropriate hold and told RN-B to take the patient's arm and bring it down to the side, and hold it above and below the elbow like he was doing. BHT-D said RN-B then changed the arm position as directed. Then BHT-D asked what does RN-B want to do. RN-B directed they would take Patient 1 to seclusion. BHT-D said he asked the patient to cooperate so it would be easier on the patient. (Note this was not coming from the RN that is supposed to be the trained person in charge of this kind of situation). BHT-D said Patient 1 was cooperative going to seclusion and all they had to do was hold the patient's arms loosely. Then BHT-D returned to the PPC unit, finished charting and left at the end of the shift. BHT-D indicated that usually they have a debriefing following a restraint/seclusion episode, but they did not that day. He added normally the RN is the one who leads and also holds the debriefing, but RN-B didn't do that. BHT-D said during the episode Patient 1 didn't say anything but was crying. He felt "bad" for the patient. He said he did not actually see RN-B grab the patient as he was already on the way over to help but he thought RN-B seemed angry. The next time he worked with LPN-E and BHT-C they talked about what happened and put all their stories together, they also knew Patient 1 had bruises from the incident and they knew they needed to report it. They went to the Director of Behavior Health with their report when the Director came in on the morning of 5/23/12.

Review of Internet articles related to the management of aggressive and violent behavior in the psychiatric setting found an article on Nursing Management of Aggression updated on 1/22/11 under the Psychiatric Nursing website, www.nursingplanet.com/pn/nursing_management_aggression .html. The article discusses the nursing process in the clinical management of the psychiatric crisis situation. It states that "Effective crisis management must be organized and should be directed by one clearly identified crisis leader." "Assemble a crisis team. Devise a plan to manage crisis and inform team. Assign securing pf patient's limbs to crisis team members. Explain necessity of intervention to patient and attempt to enlist cooperation. Restrain patient when decided by the crisis leader. Maintain calm consistent approach to patient. Review crisis management interventions with crisis team." Another web site article titled Managing the Aggressive and Violent Patient in the Psychiatric Emergency can be found at www.sciencedirect.com. The article was accepted in January 2006. It states if all less restrictive interventions have been ineffective, it could be necessary to use restraint or seclusion. "This comports [leads to] the actuation of risky procedures that have to be done properly by well trained and experienced staff to avoid physical and psychological traumas or even death. It is crucial to have enough people to do the last attempt of show of force and to act the intervention in the safest and quickest way. It is suggested a minimum of 5 staff members." When the decision has been made by the staff leader that the patient requires seclusion or restraint, the leader should perform a short briefing to define details and roles of the staff members on the team. At this point generally it is too late for any negotiation with the patient, however the patient should be informed on what is going to happen and asked to cooperate. This article indicates the standard of practice, minimum number of staff, to safely take an aggressive patient that is out of control to seclusion or to place in restraints is 5. This includes a leader, and at least 1 staff member that can be assigned to safely secure each limb.

The facility policy and procedure for restraints and seclusion was last revised 3/2012. The policy states "Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others, and must be discontinued at the earliest possible time. Alternative interventions should be utilized, unless safety issues demand an immediate physical response.... Patients have the right to be free from the use of restraint/seclusion of any form as a means of coercion, discipline, convenience or retaliation by staff." Further in the policy it states "Debriefing is important in reducing the recurrent use of restraint/seclusion. All staff members involved in initiating a behavioral restraint/seclusion will participate in a staff debriefing of the intervention. Debriefing occurs as soon as possible but no longer that 24 hours after an episode." In the facility's policy and procedure for "Dr. Strong" last revised 7/2010, the purpose of the policy is noted as "When circumstances warrant the need for interventions with individuals who exhibit threatening or assaulting behavior, all interventions should provide for the care, welfare, safety, and security of all persons involved." Further in this policy it directs, "In response to the page of Dr. Strong, all available employees will respond to the call for assistance. It is not recommended that one person physically intervene alone with an acting-out person. It is recommended that only staff that are CPI (Crisis Prevention Intervention) certified respond." "Upon arriving, employees will take direction from the charge nurse, nursing supervisor, or the team leader. The crisis should be managed with the appropriate number as deemed necessary to control the acting out person."

On 5/17/12 at 6:25 AM, Patient 1 had been pacing the hall ways on the IPC unit throughout the night shift. The Physician's Progress Notes for 5/17/12 noted the patient was agitated which progressively worsened during the previous night shift. The patient was not threatening or aggressive towards RN-B when RN-B finally came out of the nurse's station at 6:27 AM after learning the patient had thrown a plastic cup lid at the other staff member who was in the nurse's station behind a locked door. No other intervention was utilized at that time with the patient, who was grabbed by RN-B and forcibly pushed down the hall to the patient's room. Did the behavior of the patient prior to being grabbed by RN-B warrant seclusion? Based on documentation, the patient was not offered any medication, the physician was not notified of the patient's agitation for direction that may have helped the patient to be calmer and to be able to get some rest during the night. RN-B did not follow the training expectations of CPI and did not follow the restraint/seclusion policy or the Doctor Strong policy. Review of the video of the incident revealed the appearance of an angry response of RN-B towards the patient. The facility failed to ensure staff implemented safe and appropriate restraint/seclusion techniques and followed the facility's policies and procedures to manage behaviors of a manic and delusional patient resulting in injury to the patient.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0166
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review, staff interview and restraint policy review the facility failed to ensure the patient's plan of care was modified to reflect the use of seclusion for 1 of 2 sampled patients (Patient 3) who required a behavioral seclusion intervention. The total sample size was 10. The total facility census was 52. 16 patients were located in a separate Behavioral Health Services building. Findings are:

A. Medical Record review for current inpatient (Patient 3) revealed the patient was admitted on [DATE] under an Emergency Protective Custody (EPC). Diagnoses include depressive disorder with severe psychosis. On 6/30/12 the patient was placed in locked seclusion secondary to behaviors that were a danger to self and others. The patient was suicidal, kicking biting and striking out at staff. He was placed in seclusion at 9:40 AM and was released at 12:25 PM. Later the same day, 6/30/12., the patient required use of seclusion again for the same behaviors. The patient was placed in seclusion from 5:40 PM until 9:40 PM when the patient met release criteria. Record review of the plan of care revealed the use of seclusion/restraint was not identified or included in interventions for this patient.

B. Staff interview with Registered Nurse (RN) A, Executive Director of Behavioral Health Services on 7/10/12 at 2:00 PM after reviewing the patient record and plan of care confirmed the use of seclusion/restraint was not incorporated into the patient's plan of care as required by facility policy.

C. Record review of facility policy titled "Nursing Departments Policy and Procedure Restraints and Seclusion; CMS notification" last revised 3/12 states under section E tiled "Documentation" that "The restraint/seclusion must be added to the care plan with nursing interventions and desired outcomes stated."
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0178
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review, staff interview, and restraint policy review the facility failed to ensure 1 of 2 patients requiring use of behavioral seclusion (Patient 3) had the required face to face evaluation done within the 1 hour required time frame for the second seclusion episode on 6/30/12. Review of the facility policy for the face to face evaluation does not meet the regulatory requirements. The sample was 10. The facility census was 52 with 16 patients in a separate Behavioral Health Services building. Findings are:

A. Medical Record review for current inpatient (Patient 3) revealed the patient was admitted on [DATE] under an Emergency Protective Custody (EPC). Diagnoses include depressive disorder with severe psychosis. On 6/30/12 the patient was placed in locked seclusion secondary to behaviors that were a danger to self and others. The patient was suicidal, kicking biting and striking out at staff. He was placed in seclusion at 9:40 AM and was released at 12:25 PM. A face to face evaluation was made within an hour of initiation of seclusion by the psychiatrist. Later the same day, 6/30/12, the patient required use of seclusion again for the same behaviors. The patient was placed in seclusion from 5:40 PM until 9:40 PM when the patient met release criteria. Review of the medical record failed to find documentation of a face to face evaluation of the patient after initiation of seclusion.

B. Staff interview with Registered Nurse (RN-A), Executive Director of the Behavioral Health Services, on 7/10/12 at 3:30 PM revealed that "We interpreted the face to face in 1 hour was only required with the first restraint order in 24 hours, if the patient has the same behavior another face to face is not needed unless a new behavior occurs even with a new restraint/seclusion order within 24 hours. RN A confirmed a face to face evaluation of the patient by a specially trained RN, NP (Nurse Practitioner), PA (Physician Assistant) or physician was not documented for Patient 3 related to the second seclusion episode that occurred on 6/30/12 from 5:40 PM until 9:40 PM.

C. Record review of facility policy titled "Nursing Departments Policy and Procedure Restraints and Seclusion; CMS notification" last revised 3/12 states under section D titled "Monitoring and Assessment guidelines that "If violent restraint/seclusion is terminated early and the same behavior is still evident within the original restraint order time frame, a new order must be obtained for restraint/seclusion however, another face to face is not required with this order. Any new behaviors or threats would require a face to face evaluation. " Under section E titled "Documentation" the policy states The physician, NP, PA or specially trained RN will document their one hour face-to-face assessment." This policy does not meet the requirement for a face to face evaluation within 1 hour of the application of restraint/seclusion.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0202
Based on review of the facility's internal investigation, review of policies and procedures, and staff interviews the facility failed to ensure security officers working at the Behavioral Health Services (BHS) campus were trained in Crisis Prevention Intervention (CPI) and/or trained in assisting BHS staff in the management of aggressive, threatening patients requiring restraint or seclusion even though security officers were expected to respond to psychiatric emergencies. The census on the day of entrance was 52 including 16 patients on the BHS campus that was approximately 1 mile from the main hospital campus. Findings are:

The facility self-reported an incident of staff to patient abuse that occurred on 5/17/12 at 6:27 AM on the Intensive Psychiatric Care (IPC) unit on the BHS campus. The facility accepts Emergency Protective Custody patients to this unit (EPC is a involuntary order of admission completed by a law enforcement officer when a patient is a danger to themselves or to others). Review of the facility's investigation revealed there were 4 staff working on the night shift on the IPC and the Progressive Psychiatric Care (PPC) units when the incident occurred. An interview with the Director of Behavioral Health Services beginning on 7/11/12 at 10:00 AM revealed at night the only people in the BHS building are the unit staff and 1 security officer. The staffing on the unit is based on the census. An interview with RN-A completed on 7/12/12 at 10:45 AM confirmed a security guard is always on duty at the BHS building and they are off-duty law enforcement. RN-A stated the security officer on duty on the night of the incident (S-F) had not had CPI training or training on assisting nursing staff with restraint and seclusion of a patient. RN-A confirmed that none of the security staff had been trained. RN-A also confirmed that security staff are expected to respond to a psychiatric crisis situation when there is a call for "Doctor Strong" (a policy and procedure that names the alert and the expectations of staff when a patient is acting out in a threatening and assaultive manner requiring intervention of seclusion or restraint).

Review of the Policy and Procedure titled Dr. Strong, last revised 7/2010, found the policy directs "In response to the page of Dr. Strong, all available employees will respond to the call for assistance....It is recommended that only staff that are CPI certified respond." Despite the policy and procedure recommendations, and the fact that there are times when the only other person in the building to respond is the security officer, the facility has not provided or required security staff to have the training in CPI or in assisting staff with managing a out of control patient needing restraint or seclusion for the safety of the patient, staff and others.