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.

CAROLINAS MEDICAL CENTER/BEHAV HEALTH 1000 BLYTHE BLVD CHARLOTTE, NC 28203 Feb. 10, 2011
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on policy and procedure reviews, open and closed medical record reviews, incident report reviews, grievance file reviews, restraint/seclusion education training material reviews, observations of a staff return demonstration, staffing schedule reviews, personnel file reviews, and staff interviews, the hospital's nursing staff failed to protect and promote patient's rights for a safe environment as evidenced by failing to implement restraints in accordance with safe and appropriate restraint techniques resulting in a patient injury.

The findings include:

1. The hospital's nursing staff failed to provide care in a safe setting as evidenced by failure to implement restraints in accordance with safe and appropriate restraint techniques resulting in an injury for 1 of 1 patients injured during a restraint (#6).

~cross refer to 482.13(c)(2) Patients' Rights Standard: Tag A0144

2. The hospital's nursing staff failed to implement restraints in accordance with safe and appropriate restraint techniques resulting in an injury for 1 of 1 patients injured during a restraint (#6).

~cross refer to 482.13(e)(4)(ii) Patients' Rights Standard: Tag A0167
VIOLATION: NURSING SERVICES Tag No: A0385
Based on policy and procedure reviews, open and closed medical record reviews, incident report reviews, grievance file reviews, restraint/seclusion education training material reviews, observations of a staff return demonstration, staffing schedule reviews, personnel file reviews, and staff interviews, the hospital's nursing staff failed to have an effective nursing service providing oversight of day to day operations by failing to ensure nursing staff implemented restraints in accordance with safe and appropriate restraint techniques.

The findings include:

The hospital's nursing staff failed to supervise and monitor restrictive intervention techniques in order to ensure restraints were implemented in accordance with safe and appropriate restraint techniques to prevent injury for 1 of 1 patients sampled injured during a restraint (#6).

~cross refer 482.23(b)(3) Nursing Services Standard: Nursing Supervision, Tag A0395
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy and procedure reviews, open and closed medical record reviews, incident report reviews, grievance file reviews, restraint/seclusion education training material reviews, observations of a staff return demonstration, staffing schedule reviews, personnel file reviews, and staff interviews, the hospital's nursing staff failed to supervise and monitor restrictive intervention techniques in order to ensure restraints were implemented in accordance with safe and appropriate restraint techniques to prevent injury for 1 of 1 patients sampled injured during a restraint (#6).

The findings include:

Review of current hospital policy (specific to the psychiatric campus) entitled "Use of Seclusion/Restraint" CA-108 and NS-305, revised October 2010, revealed "...General RI (Restrictive Intervention) Information: An RI will not be used in a manner that causes abuse or harm to the patient. In all instances, efforts shall be focused on preserving the patient's safety and dignity. ...Restraint -Specific Information: ...During any hands-on, an RN must be at the head of a patient who is being manually or mechanically restrained to recognize, assess, and address any signs/symptoms of physical distress. Preferably, restraints will occur with the patient in a supine (face up) position. If a patient must be restrained in the prone position, staff will ensure that the airway is unobstructed and that expansion of the patient's lungs is not restricted. ..."

Review of current hospital policy entitled "Restrictive Interventions," reviewed/revised 7/2010 revealed "...1. Policy A. The use of restraints shall be limited to clinically appropriate and adequately justified situations in a manner that protects the patient's health and safety and preserves the patient's dignity, rights, and well being..."

Closed medical record review on 02/09/2011 for Patient #6 revealed, a [AGE] year old male who presented to the hospital's psychiatric campus emergency department (ED) on 01/27/2011 at 1829 with a chief complaint of "...Pt (patient) is autistic and has been increasingly agitated ....had rage, choked Grandmother, Bit Stepfather, broke window at house." Record review revealed the patient was brought to the ED by the Police, in hand cuffs. Record review revealed a past medical history of Autistic Disorder and Mental Retardation (MR). Record review revealed the patient was "non-verbal with minimal verbalizations." Record review revealed the patient was subsequently admitted for observation with a diagnosis of Autistic Disorder to the ED Pediatric Observation Unit and was discharged on [DATE] at 1112.

Review of a Restrictive Intervention Order and Face-to-Face Assessment form dated 01/29/2011 at 1245 and signed by Physician A, revealed a physician's order for manual restraint for patient behaviors that constituted an immediate and serious danger to the physical safety of the patient or others.

Review of electronic "Restraint Documentation" on 01/29/2011, revealed documentation by Nurse #1 that Patient #6 had been placed into a RI at 12:45. Review revealed the RI was discontinued at 12:50 (duration 5 minutes). Review revealed documentation at 1258 by Nurse #1 of a "Physical Assess(ment) Upon RI initiation: WNL (within normal limits)." Further review revealed documentation at 1258 by Nurse #1 of "Injury Related to Restraint Applica(tion): YES, MD notified." Review of a "Comment: Notified Dr. (Physician A name) of abrasions, no orders at this time." Further review revealed documentation at 1258 by Nurse #1 of "Explain Injury: Pt (patient) with multiple abrasions to face, arms, back, and torso."

Review of an electronic "Behavioral Health Documentation" form dated 1/29/2011 at 12:45 by Psychiatric Technician #2 (Psych Tech #2), revealed "Pt's grandmother was present at time of restraint. Grandmother was witness to abrasions that occurred due to physical aggression of patient. Step father was present at ER (emergency room ) but in outer lobby, however peering through secure doors during restraint."

Review of a Restrictive Intervention Order and Face-to-Face Assessment form dated 01/29/2011 and signed by Physician A at 1245 revealed documentation of a face-to-face evaluation (to be complete within 1-hr (hour) of initiation of RI ...) conducted at the time of RI initiation (1245). Further review revealed "Patient's medical condition: X marked in a box next to WNL." Further record review revealed no available documented evidence Physician A performed a re-assessment of the injuries as a result of the RI on Patient #6 as reported to her by Nurse #1 at 1258.

Interview on 02/10/2011 at 1450 with Physician A revealed she could not remember the patient specifically, however documentation in the medical record revealed she did examine the patient during the face to face assessment following the writing of the manual restraint order. Interview confirmed no available documentation in the medical record of the injuries (abrasions and bruising) sustained by Patient #6 after the application of restraint on 01/29/2010 at 1245.

Review of an incident report for Patient #6 completed on 01/29/2011 by Nurse #1 revealed on 01/29/2011 at 1245 "Pt became aggressive while visiting with grandmother, staff separated pt and grandmother at that time pt started kicking, hitting and biting at staff. Pt manually restrained and medicated." Further review revealed "Severity of Injury: Level 3 - Temporary harm that required some treatment."

Review of complaint/grievance documentation dated 02/01/2011 revealed a grievance was filed with hospital administration via voice mail message on 02/01/2011 on behalf of Patient #6 by a family member. Review revealed a complaint of "...(Patient #6 name) was improperly restrained on January 29 ...He personally saw the incident and caught the staff pushing (Patient #6 name) head through the carpet ..."

Review of electronic mail documentation by Nurse #3 (unit nurse manager) revealed "I spoke with (family member name) on 02/02/2011. He spoke of observing through crack in door and felt 2 male staff restraining the pt was excessive as he is able to restrain (Patient #6) on his own at home. He reported bruises on (Patient #6) face and back. ...I told him there would be an investigation (I have spoken with 4 of the 5 staff involved) ...Letter attached and complaint closed."

Review of complaint/grievance investigation documentation on 02/09/2011 revealed Nurse #3 (unit nurse manager) conducted an interview on 02/04/2011 at 1438 with the unit charge nurse (Nurse #2) on duty the date of incident (01/29/2010 at 1245) involving Patient #6. Further review revealed "When she (Nurse #2) entered peds SL (secure lobby), patient was on floor in manual restraint. She reports seeing patient trying to bite staff, moving his head and no one was holding his head. She reports (Patient #6) was taking forehead and scraping it on the carpet. Reports RI was handled appropriately, no one was laying on legs ...(Nurse #2 name) reports medications were obtained. (Nurse #2 name) reports nothing inappropriate was witnessed. ...Reports (family member) was peeking through door crack during situation."

Further review of the complaint/grievance investigation documentation revealed Nurse #3 conducted an interview with Psych Tech #1 on 02/02/2011 at 1500. Review revealed "He reports that when grandmother (GM) who is guardian of patient went to leave, patient escalated. He 'flopped' on the floor. GM sat down and with staff redirection, patient was able to de-escalate and sat in chair. GM went to leave again and patient 'threw a fit,' he hit Psych Tech #1, was kicking, screaming and cursing. At that time a manual restraint occurred due to safety issues. Patient was squirming, moving, trying to bite staff and continued to kick and yell. Within a few minutes patient was able to walk into quite room where he received medication."

Further review of the complaint/grievance investigation documentation revealed Nurse #3 conducted an interview with Nurse #1 on 02/04/2011 at 1441. Review revealed "Reports saw patient push GM and getting loud. She went to get prn po (as needed by mouth) medication (Thorazine). When she returned to peds secure lobby, manual RI was in place due to patient trying to bite, kicking, and hitting. She reports nothing was over his face. She reports went back into work station to get order for IM medication and (Nurse #2 name) was then present. Reports patient walked to quiet room on own and received medication. Reports never saw face restricted. Reports hands on either side of head (at ears) to prevent biting. She reports seeing nothing inappropriate from staff."

Further review of the complaint/grievance investigation documentation revealed no available documentation Nurse #3 interviewed Psych Tech #2 regarding the RI involving Patient #6 on 01/29/2011 as of 02/09/2011.

Interview on 02/09/2011 at 1200 with the hospital's CPI (Crisis Prevention Intervention) Master Instructor (#1) revealed, CPI is the approved curriculum taught to hospital staff involved in the application of restrictive interventions. Interview revealed CPI teaches approved and appropriate techniques for the application of manual restraints. Interview revealed staff do receive training upon hire and annually thereafter. Interview revealed patients can be restrained in a prone (face down) position on their stomach when using the appropriate CPI technique. Interview revealed CPI has only one (1) approved technique for floor restraint called the CPI Team Control Position "Emergency Floor Procedure" where the patient is on the floor on his/her stomach and is manually restrained and assisted up off of the floor. Interview revealed the Emergency Floor Procedure requires two staff members to perform. Interview revealed it is not appropriate for one staff member to perform a floor restraint.

Review on 02/09/2011 of the CPI training material (dated 2006-2007) presented, revealed the CPI Team Control Position "Emergency Floor Procedure" for manual restraint is a two person procedure used on an individual who is on their stomach. Review revealed "Remember: The floor is a dangerous place to be when restraining someone. It should always be viewed as an interim position, with a goal of returning the person to the CPI Team Control Position as soon as possible ....If the acting-out person falls or drops to the floor, or is injuring himself on the floor, always consider the option of disengaging. If the person is not a danger to self or others while on the floor, staff may make the decision to move away and give a clear directive. If the team decides that disengaging is not a safe alternative and the individual is on the floor: Step 1 is to Position yourself seated and to the side of the individual (one person on each side of the individual). Continue to maintain control of the person's arms by securing them to your hip area. Your forearm (free arm) is positioned in front of the individual's shoulder. This minimizes any pressure being placed on the back. Note: the weight of each staff member is distributed among hips, legs, and forearms. Their weight is not resting on the person being restrained. Close body contact is designed to limit, but not totally prevent, mobility. Allowing the person to move his hips, chest, and abdomen also allows the individual to breathe more freely. To reduce the risk of positional asphyxia, be sure that you do NOT hold the person's legs, lean on the person's back, or put pressure on the shoulders. Step 2 Place the person's hands on the floor as you move to your hands and knees while maintaining close body contact. Ensure that the person's arms are placed wider than the shoulders so that he cannot generate too much leverage. Step 3 Allow the person to raise himself off the floor. Step 4 Bring your inside arm behind and under the person's arms using the crux of the elbow to provide support. Raise your inside leg in preparation for standing. Step 5 Maintain close body contact as you move up and forward at a 45-degree angle. As the person moves to his feet, you can place the person in either the CPI Team control Position or the CPI Transport Position."

Observation on 02/09/2011 at 1740 of a return demonstration provided by Psych Tech #1 and Psych Tech #2 with the assistance of another staff member (who played the role of Patient #6) demonstrated how they applied the manual restraint to Patient #6 on 01/29/2011 at 1245. Observation revealed the patient was initially on the floor supine, kicking, and waving arms. Further observation revealed Psych Tech #1 was attempting to hold the patient's legs down to the floor (from the distal feet location, not from the sides of the patient's legs) while the patient was supine in order to prevent kicking. Observation revealed Psych Tech #1 was holding the patient around the ankles to mid-calf location. Further observation revealed the patient's arms, head, and torso were not restrained and able to move freely. Further observation revealed Psych Tech #2 entered the area to assist. Observation revealed as Psych Tech #1 continued to hold the patient's legs down (with no change in technique or location) when the patient abruptly "flipped" over onto the stomach (face-down). Observation revealed Psych Tech #1 continued to hold the patients feet (with no change in technique or location). Further observation revealed Psych Tech #2 approached the patient from the patient's left side and grabbed the patient's left arm and placed it into a stretched out secured position with the left shoulder held to the floor. Observation revealed the patients head and right arm were still able to move freely. Further observation revealed Psych Tech #2 reached across the patient while immobilizing the left arm and grabbed the right arm and placed them both up under the patient's chest in a crossed position. Observation revealed the two psychiatric technicians then lifted the patient up off the floor in order to carry the patient to the quiet room. Observation revealed Psych Tech #2 carried the upper torso and Psych Tech #1 carried the lower torso/legs. Interview immediately after the observation with Psych Tech #1 and #2 revealed the demonstration to be an accurate portrayal of the RI used on Patient #6 on 01/29/2011 at 1245.

Note: Prior to the start of the demonstration the two Psychiatric Technicians were given instructions by the Surveyor to describe in detail to the staff member playing the role of Patient #6 the behaviors displayed by the patient during the restrictive intervention. The demonstration was conducted with hospital nursing unit management staff, administrative management staff, and CPI Master Instructors present.

Interview on 02/09/2011 at 1750 with the unit nurse manager (a former CPI Master Instructor #2), CPI Master Instructor #1, and administrative management staff present during the return demonstration by Psych Tech #1 and #2 revealed the two staff members failed to perform appropriate and approved restraint techniques. Interview revealed they did not perform the Emergency Floor Procedure appropriately, by holding the patient's feet down and not being in an appropriate position to protect the patient head. Interview revealed if the staff members performed the procedure appropriately they would have been able to have some control over the patient's head movements thus possibly preventing rug burns and abrasions to the head and face. Further interview confirmed the two psychiatric technicians failed to implement restraints in accordance with safe and appropriate restraint techniques resulting in an injury to Patient #6 on 01/29/2010. Interview revealed "the two psychiatric technicians needed to have a refresher in appropriate restraint techniques." Interview further revealed no new education or training had been provided nor monitoring conducted for the two psychiatric technicians nor other staff members involved in the use of restraint/seclusion since the incident on 01/29/2011.

Telephone interview on 02/09/2011 at 1230 with Nurse #2 revealed she was on duty the day Patient #6 was placed in a RI on 01/29/2011. Interview revealed Psych Tech #1 and #2 were placing the patient into a RI. Interview revealed she was "just observing." Interview revealed the patient was lying on his stomach with his head held up. Interview revealed she went to get the security guard. Interview revealed she was not sure of what the security guard did during the RI. Interview revealed she does not use the floor restraint as much as other RI techniques. Interview revealed after the RI was discontinued she noted Patient #6 had abrasions to his forehead, and one arm. Interview revealed she notified Physician A and the physician examined the patient.

Telephone interview on 02/09/2011 at 1250 with Nurse #1 revealed she was on duty the day Patient #6 was placed in a RI on 01/29/2011. Interview revealed she first saw the patient becoming aggressive and went to get a PRN medication. Interview revealed when she returned the patient was being manually restrained by Psych Tech #1 and #2. Interview revealed the patient was on his back and one tech was holding the patients head and the other technician was holding the arms and body of the patient. Interview revealed the RI lasted 5-10 minutes. Interview revealed the patient was moved to the quiet room from the lobby then given Thorazine.

Telephone interview with Psych Tech #2 on 02/09/2011 at 1320 revealed he was on duty when Patient #6 was placed into a RI on 01/29/2011. Interview revealed he had stepped into the peds (pediatric) secure lobby to help Psych Tech #1 who was holding Patient #6's feet to keep him from kicking. Interview revealed Patient #6 was on the floor squirming around. Interview revealed himself and Psych Tech #1 were trying to control the patient. The patient then flipped over onto his stomach (face-down). Interview revealed he was in front of the patient trying to stop him from swinging his arms and biting. Interview revealed the other staff member (Psych Tech #1) was holding the patient's legs. Interview revealed two nurses (Nurse #1 and #2) were present but did not participate in the RI.

Interview with Psych Tech #1 on 02/09/2011 at 1517, revealed Patient #6 was becoming agitated and aggressive, kicking and screaming when he thought his grandmother was going to leave. The patient had been sitting in a wooden chair at a table, with his grandmother present. He "flopped" himself to the floor and the staff attempted to get the patient back into his seat without success. Interview revealed the patient ended up on his back initially then turned himself onto his stomach (face-down). Interview revealed Psych Tech #1 got hold of the patient's feet to control the kicking and Psych Tech #2 was attempting to control the patient's arms. Interview revealed Psych Tech #1 indicated this all took place with-in a 2 to 3 minute time frame. Interview revealed two nurses (Nurse #1 and #2) came into the area 1-2 minutes later and instructed them to move the patient to the quiet room. Further interview revealed the two psychiatric technicians then picked the patient up off the floor, by one picking up the feet (Psych Tech #1) and the other picking up the patient's upper torso (Psych Tech #2). Interview revealed the patient was in a face-down position, carrying the patient to the quiet room. Interview revealed the patient was administered an injection by the nurse (Thorazine 50 milligrams Intramuscular).

Review on 02/10/2010 of staffing schedules for 01/29/2011 to 02/10/2011, revealed Psych Tech #1 staffed shifts on 01/30, 01/31, 02/01, 02/02, 02/03, 02/05, 02/06, 02/07, 02/08, and 02/09/2011 and Psych Tech #2 worked on 01/30, 02/02, 02/05, 02/06, and 02/09/11 without any re-education or refresher training in appropriate CPI techniques.

Review of the Personnel File for Psych Tech #1 revealed his current CPI training expires on 06/23/2011.

Review of the Personnel File for Psych Tech #2 revealed his current CPI training expires on 06/23/2011.

NC 644
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0167
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy and procedure reviews, open and closed medical record reviews, incident report reviews, grievance file reviews, restraint/seclusion education training material reviews, observations of a staff return demonstration, staffing schedule reviews, personnel file reviews, and staff interviews, the hospital's nursing staff failed to implement restraints in accordance with safe and appropriate restraint techniques resulting in an injury for 1 of 1 patients injured during a restraint (#6).

The findings include:

Review of current hospital policy (specific to the psychiatric campus) entitled "Use of Seclusion/Restraint" CA-108 and NS-305, revised October 2010, revealed "...General RI (Restrictive Intervention) Information: An RI will not be used in a manner that causes abuse or harm to the patient. In all instances, efforts shall be focused on preserving the patient's safety and dignity. ...Restraint -Specific Information: ...During any hands-on, an RN must be at the head of a patient who is being manually or mechanically restrained to recognize, assess, and address any signs/symptoms of physical distress. Preferably, restraints will occur with the patient in a supine (face up) position. If a patient must be restrained in the prone position, staff will ensure that the airway is unobstructed and that expansion of the patient's lungs is not restricted. ..."

Review of current hospital policy entitled "Restrictive Interventions," reviewed/revised 7/2010 revealed "...1. Policy A. The use of restraints shall be limited to clinically appropriate and adequately justified situations in a manner that protects the patient's health and safety and preserves the patient's dignity, rights, and well being..."

Closed medical record review on 02/09/2011 for Patient #6 revealed, a [AGE] year old male who presented to the hospital's psychiatric campus emergency department (ED) on 01/27/2011 at 1829 with a chief complaint of "...Pt (patient) is autistic and has been increasingly agitated ....had rage, choked Grandmother, Bit Stepfather, broke window at house." Record review revealed the patient was brought to the ED by the Police, in hand cuffs. Record review revealed a past medical history of Autistic Disorder and Mental Retardation (MR). Record review revealed the patient was "non-verbal with minimal verbalizations." Record review revealed the patient was subsequently admitted for observation with a diagnosis of Autistic Disorder to the ED Pediatric Observation Unit and was discharged on [DATE] at 1112.

Review of a Restrictive Intervention Order and Face-to-Face Assessment form dated 01/29/2011 at 1245 and signed by Physician A, revealed a physician's order for manual restraint for patient behaviors that constituted an immediate and serious danger to the physical safety of the patient or others.

Review of electronic "Restraint Documentation" on 01/29/2011, revealed documentation by Nurse #1 that Patient #6 had been placed into a RI at 12:45. Review revealed the RI was discontinued at 12:50 (duration 5 minutes). Review revealed documentation at 1258 by Nurse #1 of a "Physical Assess(ment) Upon RI initiation: WNL (within normal limits)." Further review revealed documentation at 1258 by Nurse #1 of "Injury Related to Restraint Applica(tion): YES, MD notified." Review of a "Comment: Notified Dr. (Physician A name) of abrasions, no orders at this time." Further review revealed documentation at 1258 by Nurse #1 of "Explain Injury: Pt (patient) with multiple abrasions to face, arms, back, and torso."

Review of an electronic "Behavioral Health Documentation" form dated 1/29/2011 at 12:45 by Psychiatric Technician #2 (Psych Tech #2), revealed "Pt's grandmother was present at time of restraint. Grandmother was witness to abrasions that occurred due to physical aggression of patient. Step father was present at ER (emergency room ) but in outer lobby, however peering through secure doors during restraint."

Review of a Restrictive Intervention Order and Face-to-Face Assessment form dated 01/29/2011 and signed by Physician A at 1245 revealed documentation of a face-to-face evaluation (to be complete within 1-hr (hour) of initiation of RI ...) conducted at the time of RI initiation (1245). Further review revealed "Patient's medical condition: X marked in a box next to WNL." Further record review revealed no available documented evidence Physician A performed a re-assessment of the injuries as a result of the RI on Patient #6 as reported to her by Nurse #1 at 1258.

Interview on 02/10/2011 at 1450 with Physician A revealed she could not remember the patient specifically, however documentation in the medical record revealed she did examine the patient during the face to face assessment following the writing of the manual restraint order. Interview confirmed no available documentation in the medical record of the injuries (abrasions and bruising) sustained by Patient #6 after the application of restraint on 01/29/2010 at 1245.

Review of an incident report for Patient #6 completed on 01/29/2011 by Nurse #1 revealed on 01/29/2011 at 1245 "Pt became aggressive while visiting with grandmother, staff separated pt and grandmother at that time pt started kicking, hitting and biting at staff. Pt manually restrained and medicated." Further review revealed "Severity of Injury: Level 3 - Temporary harm that required some treatment."

Review of complaint/grievance documentation dated 02/01/2011 revealed a grievance was filed with hospital administration via voice mail message on 02/01/2011 on behalf of Patient #6 by a family member. Review revealed a complaint of "...(Patient #6 name) was improperly restrained on January 29 ...He personally saw the incident and caught the staff pushing (Patient #6 name) head through the carpet ..."

Review of electronic mail documentation by Nurse #3 (unit nurse manager) revealed "I spoke with (family member name) on 02/02/2011. He spoke of observing through crack in door and felt 2 male staff restraining the pt was excessive as he is able to restrain (Patient #6) on his own at home. He reported bruises on (Patient #6) face and back. ...I told him there would be an investigation (I have spoken with 4 of the 5 staff involved) ...Letter attached and complaint closed."

Review of complaint/grievance investigation documentation on 02/09/2011 revealed Nurse #3 (unit nurse manager) conducted an interview on 02/04/2011 at 1438 with the unit charge nurse (Nurse #2) on duty the date of incident (01/29/2010 at 1245) involving Patient #6. Further review revealed "When she (Nurse #2) entered peds SL (secure lobby), patient was on floor in manual restraint. She reports seeing patient trying to bite staff, moving his head and no one was holding his head. She reports (Patient #6) was taking forehead and scraping it on the carpet. Reports RI was handled appropriately, no one was laying on legs ...(Nurse #2 name) reports medications were obtained. (Nurse #2 name) reports nothing inappropriate was witnessed. ...Reports (family member) was peeking through door crack during situation."

Further review of the complaint/grievance investigation documentation revealed Nurse #3 conducted an interview with Psych Tech #1 on 02/02/2011 at 1500. Review revealed "He reports that when grandmother (GM) who is guardian of patient went to leave, patient escalated. He 'flopped' on the floor. GM sat down and with staff redirection, patient was able to de-escalate and sat in chair. GM went to leave again and patient 'threw a fit,' he hit Psych Tech #1, was kicking, screaming and cursing. At that time a manual restraint occurred due to safety issues. Patient was squirming, moving, trying to bite staff and continued to kick and yell. Within a few minutes patient was able to walk into quite room where he received medication."

Further review of the complaint/grievance investigation documentation revealed Nurse #3 conducted an interview with Nurse #1 on 02/04/2011 at 1441. Review revealed "Reports saw patient push GM and getting loud. She went to get prn po (as needed by mouth) medication (Thorazine). When she returned to peds secure lobby, manual RI was in place due to patient trying to bite, kicking, and hitting. She reports nothing was over his face. She reports went back into work station to get order for IM medication and (Nurse #2 name) was then present. Reports patient walked to quiet room on own and received medication. Reports never saw face restricted. Reports hands on either side of head (at ears) to prevent biting. She reports seeing nothing inappropriate from staff."

Further review of the complaint/grievance investigation documentation revealed no available documentation Nurse #3 interviewed Psych Tech #2 regarding the RI involving Patient #6 on 01/29/2011 as of 02/09/2011.

Interview on 02/09/2011 at 1200 with the hospital's CPI (Crisis Prevention Intervention) Master Instructor (#1) revealed, CPI is the approved curriculum taught to hospital staff involved in the application of restrictive interventions. Interview revealed CPI teaches approved and appropriate techniques for the application of manual restraints. Interview revealed staff do receive training upon hire and annually thereafter. Interview revealed patients can be restrained in a prone (face down) position on their stomach when using the appropriate CPI technique. Interview revealed CPI has only one (1) approved technique for floor restraint called the CPI Team Control Position "Emergency Floor Procedure" where the patient is on the floor on his/her stomach and is manually restrained and assisted up off of the floor. Interview revealed the Emergency Floor Procedure requires two staff members to perform. Interview revealed it is not appropriate for one staff member to perform a floor restraint.

Review on 02/09/2011 of the CPI training material (dated 2006-2007) presented, revealed the CPI Team Control Position "Emergency Floor Procedure" for manual restraint is a two person procedure used on an individual who is on their stomach. Review revealed "Remember: The floor is a dangerous place to be when restraining someone. It should always be viewed as an interim position, with a goal of returning the person to the CPI Team Control Position as soon as possible ....If the acting-out person falls or drops to the floor, or is injuring himself on the floor, always consider the option of disengaging. If the person is not a danger to self or others while on the floor, staff may make the decision to move away and give a clear directive. If the team decides that disengaging is not a safe alternative and the individual is on the floor: Step 1 is to Position yourself seated and to the side of the individual (one person on each side of the individual). Continue to maintain control of the person's arms by securing them to your hip area. Your forearm (free arm) is positioned in front of the individual's shoulder. This minimizes any pressure being placed on the back. Note: the weight of each staff member is distributed among hips, legs, and forearms. Their weight is not resting on the person being restrained. Close body contact is designed to limit, but not totally prevent, mobility. Allowing the person to move his hips, chest, and abdomen also allows the individual to breathe more freely. To reduce the risk of positional asphyxia, be sure that you do NOT hold the person's legs, lean on the person's back, or put pressure on the shoulders. Step 2 Place the person's hands on the floor as you move to your hands and knees while maintaining close body contact. Ensure that the person's arms are placed wider than the shoulders so that he cannot generate too much leverage. Step 3 Allow the person to raise himself off the floor. Step 4 Bring your inside arm behind and under the person's arms using the crux of the elbow to provide support. Raise your inside leg in preparation for standing. Step 5 Maintain close body contact as you move up and forward at a 45-degree angle. As the person moves to his feet, you can place the person in either the CPI Team control Position or the CPI Transport Position."

Observation on 02/09/2011 at 1740 of a return demonstration provided by Psych Tech #1 and Psych Tech #2 with the assistance of another staff member (who played the role of Patient #6) demonstrated how they applied the manual restraint to Patient #6 on 01/29/2011 at 1245. Observation revealed the patient was initially on the floor supine, kicking, and waving arms. Further observation revealed Psych Tech #1 was attempting to hold the patient's legs down to the floor (from the distal feet location, not from the sides of the patient's legs) while the patient was supine in order to prevent kicking. Observation revealed Psych Tech #1 was holding the patient around the ankles to mid-calf location. Further observation revealed the patient's arms, head, and torso were not restrained and able to move freely. Further observation revealed Psych Tech #2 entered the area to assist. Observation revealed as Psych Tech #1 continued to hold the patient's legs down (with no change in technique or location) when the patient abruptly "flipped" over onto the stomach (face-down). Observation revealed Psych Tech #1 continued to hold the patients feet (with no change in technique or location). Further observation revealed Psych Tech #2 approached the patient from the patient's left side and grabbed the patient's left arm and placed it into a stretched out secured position with the left shoulder held to the floor. Observation revealed the patients head and right arm were still able to move freely. Further observation revealed Psych Tech #2 reached across the patient while immobilizing the left arm and grabbed the right arm and placed them both up under the patient's chest in a crossed position. Observation revealed the two psychiatric technicians then lifted the patient up off the floor in order to carry the patient to the quiet room. Observation revealed Psych Tech #2 carried the upper torso and Psych Tech #1 carried the lower torso/legs. Interview immediately after the observation with Psych Tech #1 and #2 revealed the demonstration to be an accurate portrayal of the RI used on Patient #6 on 01/29/2011 at 1245.

Note: Prior to the start of the demonstration the two Psychiatric Technicians were given instructions by the Surveyor to describe in detail to the staff member playing the role of Patient #6 the behaviors displayed by the patient during the restrictive intervention. The demonstration was conducted with hospital nursing unit management staff, administrative management staff, and CPI Master Instructors present.

Interview on 02/09/2011 at 1750 with the unit nurse manager (a former CPI Master Instructor #2), CPI Master Instructor #1, and administrative management staff present during the return demonstration by Psych Tech #1 and #2 revealed the two staff members failed to perform appropriate and approved restraint techniques. Interview revealed they did not perform the Emergency Floor Procedure appropriately, by holding the patient's feet down and not being in an appropriate position to protect the patient head. Interview revealed if the staff members performed the procedure appropriately they would have been able to have some control over the patient's head movements thus possibly preventing rug burns and abrasions to the head and face. Further interview confirmed the two psychiatric technicians failed to implement restraints in accordance with safe and appropriate restraint techniques resulting in an injury to Patient #6 on 01/29/2010. Interview revealed "the two psychiatric technicians needed to have a refresher in appropriate restraint techniques." Interview further revealed no new education or training had been provided nor monitoring conducted for the two psychiatric technicians nor other staff members involved in the use of restraint/seclusion since the incident on 01/29/2011.

Telephone interview on 02/09/2011 at 1230 with Nurse #2 revealed she was on duty the day Patient #6 was placed in a RI on 01/29/2011. Interview revealed Psych Tech #1 and #2 were placing the patient into a RI. Interview revealed she was "just observing." Interview revealed the patient was lying on his stomach with his head held up. Interview revealed she went to get the security guard. Interview revealed she was not sure of what the security guard did during the RI. Interview revealed she does not use the floor restraint as much as other RI techniques. Interview revealed after the RI was discontinued she noted Patient #6 had abrasions to his forehead, and one arm. Interview revealed she notified Physician A and the physician examined the patient.

Telephone interview on 02/09/2011 at 1250 with Nurse #1 revealed she was on duty the day Patient #6 was placed in a RI on 01/29/2011. Interview revealed she first saw the patient becoming aggressive and went to get a PRN medication. Interview revealed when she returned the patient was being manually restrained by Psych Tech #1 and #2. Interview revealed the patient was on his back and one tech was holding the patients head and the other technician was holding the arms and body of the patient. Interview revealed the RI lasted 5-10 minutes. Interview revealed the patient was moved to the quiet room from the lobby then given Thorazine.

Telephone interview with Psych Tech #2 on 02/09/2011 at 1320 revealed he was on duty when Patient #6 was placed into a RI on 01/29/2011. Interview revealed he had stepped into the peds (pediatric) secure lobby to help Psych Tech #1 who was holding Patient #6's feet to keep him from kicking. Interview revealed Patient #6 was on the floor squirming around. Interview revealed himself and Psych Tech #1 were trying to control the patient. The patient then flipped over onto his stomach (face-down). Interview revealed he was in front of the patient trying to stop him from swinging his arms and biting. Interview revealed the other staff member (Psych Tech #1) was holding the patient's legs. Interview revealed two nurses (Nurse #1 and #2) were present but did not participate in the RI.

Interview with Psych Tech #1 on 02/09/2011 at 1517, revealed Patient #6 was becoming agitated and aggressive, kicking and screaming when he thought his grandmother was going to leave. The patient had been sitting in a wooden chair at a table, with his grandmother present. He "flopped" himself to the floor and the staff attempted to get the patient back into his seat without success. Interview revealed the patient ended up on his back initially then turned himself onto his stomach (face-down). Interview revealed Psych Tech #1 got hold of the patient's feet to control the kicking and Psych Tech #2 was attempting to control the patient's arms. Interview revealed Psych Tech #1 indicated this all took place with-in a 2 to 3 minute time frame. Interview revealed two nurses (Nurse #1 and #2) came into the area 1-2 minutes later and instructed them to move the patient to the quiet room. Further interview revealed the two psychiatric technicians then picked the patient up off the floor, by one picking up the feet (Psych Tech #1) and the other picking up the patient's upper torso (Psych Tech #2). Interview revealed the patient was in a face-down position, carrying the patient to the quiet room. Interview revealed the patient was administered an injection by the nurse (Thorazine 50 milligrams Intramuscular).

Review on 02/10/2010 of staffing schedules for 01/29/2011 to 02/10/2011, revealed Psych Tech #1 staffed shifts on 01/30, 01/31, 02/01, 02/02, 02/03, 02/05, 02/06, 02/07, 02/08, and 02/09/2011 and Psych Tech #2 worked on 01/30, 02/02, 02/05, 02/06, and 02/09/11 without any re-education or refresher training in appropriate CPI techniques.

Review of the Personnel File for Psych Tech #1 revealed his current CPI training expires on 06/23/2011.

Review of the Personnel File for Psych Tech #2 revealed his current CPI training expires on 06/23/2011.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy and procedure reviews, open and closed medical record reviews, incident report reviews, grievance file reviews, restraint/seclusion education training material reviews, observations of a staff return demonstration, staffing schedule reviews, personnel file reviews, and staff interviews, the hospital's nursing staff failed to provide care in a safe setting as evidenced by failure to implement restraints in accordance with safe and appropriate restraint techniques resulting in an injury for 1 of 1 patients injured during a restraint (#6).

The findings include:

Review of current hospital policy (specific to the psychiatric campus) entitled "Use of Seclusion/Restraint" CA-108 and NS-305, revised October 2010, revealed "...General RI (Restrictive Intervention) Information: An RI will not be used in a manner that causes abuse or harm to the patient. In all instances, efforts shall be focused on preserving the patient's safety and dignity. ...Restraint -Specific Information: ...During any hands-on, an RN must be at the head of a patient who is being manually or mechanically restrained to recognize, assess, and address any signs/symptoms of physical distress. Preferably, restraints will occur with the patient in a supine (face up) position. If a patient must be restrained in the prone position, staff will ensure that the airway is unobstructed and that expansion of the patient's lungs is not restricted. ..."

Review of current hospital policy entitled "Restrictive Interventions," reviewed/revised 7/2010 revealed "...1. Policy A. The use of restraints shall be limited to clinically appropriate and adequately justified situations in a manner that protects the patient's health and safety and preserves the patient's dignity, rights, and well being..."

Closed medical record review on 02/09/2011 for Patient #6 revealed, a [AGE] year old male who presented to the hospital's psychiatric campus emergency department (ED) on 01/27/2011 at 1829 with a chief complaint of "...Pt (patient) is autistic and has been increasingly agitated ....had rage, choked Grandmother, Bit Stepfather, broke window at house." Record review revealed the patient was brought to the ED by the Police, in hand cuffs. Record review revealed a past medical history of Autistic Disorder and Mental Retardation (MR). Record review revealed the patient was "non-verbal with minimal verbalizations." Record review revealed the patient was subsequently admitted for observation with a diagnosis of Autistic Disorder to the ED Pediatric Observation Unit and was discharged on [DATE] at 1112.

Review of a Restrictive Intervention Order and Face-to-Face Assessment form dated 01/29/2011 at 1245 and signed by Physician A, revealed a physician's order for manual restraint for patient behaviors that constituted an immediate and serious danger to the physical safety of the patient or others.

Review of electronic "Restraint Documentation" on 01/29/2011, revealed documentation by Nurse #1 that Patient #6 had been placed into a RI at 12:45. Review revealed the RI was discontinued at 12:50 (duration 5 minutes). Review revealed documentation at 1258 by Nurse #1 of a "Physical Assess(ment) Upon RI initiation: WNL (within normal limits)." Further review revealed documentation at 1258 by Nurse #1 of "Injury Related to Restraint Applica(tion): YES, MD notified." Review of a "Comment: Notified Dr. (Physician A name) of abrasions, no orders at this time." Further review revealed documentation at 1258 by Nurse #1 of "Explain Injury: Pt (patient) with multiple abrasions to face, arms, back, and torso."

Review of an electronic "Behavioral Health Documentation" form dated 1/29/2011 at 12:45 by Psychiatric Technician #2 (Psych Tech #2), revealed "Pt's grandmother was present at time of restraint. Grandmother was witness to abrasions that occurred due to physical aggression of patient. Step father was present at ER (emergency room ) but in outer lobby, however peering through secure doors during restraint."

Review of a Restrictive Intervention Order and Face-to-Face Assessment form dated 01/29/2011 and signed by Physician A at 1245 revealed documentation of a face-to-face evaluation (to be complete within 1-hr (hour) of initiation of RI ...) conducted at the time of RI initiation (1245). Further review revealed "Patient's medical condition: X marked in a box next to WNL." Further record review revealed no available documented evidence Physician A performed a re-assessment of the injuries as a result of the RI on Patient #6 as reported to her by Nurse #1 at 1258.

Interview on 02/10/2011 at 1450 with Physician A revealed she could not remember the patient specifically, however documentation in the medical record revealed she did examine the patient during the face to face assessment following the writing of the manual restraint order. Interview confirmed no available documentation in the medical record of the injuries (abrasions and bruising) sustained by Patient #6 after the application of restraint on 01/29/2010 at 1245.

Review of an incident report for Patient #6 completed on 01/29/2011 by Nurse #1 revealed on 01/29/2011 at 1245 "Pt became aggressive while visiting with grandmother, staff separated pt and grandmother at that time pt started kicking, hitting and biting at staff. Pt manually restrained and medicated." Further review revealed "Severity of Injury: Level 3 - Temporary harm that required some treatment."

Review of complaint/grievance documentation dated 02/01/2011 revealed a grievance was filed with hospital administration via voice mail message on 02/01/2011 on behalf of Patient #6 by a family member. Review revealed a complaint of "...(Patient #6 name) was improperly restrained on January 29 ...He personally saw the incident and caught the staff pushing (Patient #6 name) head through the carpet ..."

Review of electronic mail documentation by Nurse #3 (unit nurse manager) revealed "I spoke with (family member name) on 02/02/2011. He spoke of observing through crack in door and felt 2 male staff restraining the pt was excessive as he is able to restrain (Patient #6) on his own at home. He reported bruises on (Patient #6) face and back. ...I told him there would be an investigation (I have spoken with 4 of the 5 staff involved) ...Letter attached and complaint closed."

Review of complaint/grievance investigation documentation on 02/09/2011 revealed Nurse #3 (unit nurse manager) conducted an interview on 02/04/2011 at 1438 with the unit charge nurse (Nurse #2) on duty the date of incident (01/29/2010 at 1245) involving Patient #6. Further review revealed "When she (Nurse #2) entered peds SL (secure lobby), patient was on floor in manual restraint. She reports seeing patient trying to bite staff, moving his head and no one was holding his head. She reports (Patient #6) was taking forehead and scraping it on the carpet. Reports RI was handled appropriately, no one was laying on legs ...(Nurse #2 name) reports medications were obtained. (Nurse #2 name) reports nothing inappropriate was witnessed. ...Reports (family member) was peeking through door crack during situation."

Further review of the complaint/grievance investigation documentation revealed Nurse #3 conducted an interview with Psych Tech #1 on 02/02/2011 at 1500. Review revealed "He reports that when grandmother (GM) who is guardian of patient went to leave, patient escalated. He 'flopped' on the floor. GM sat down and with staff redirection, patient was able to de-escalate and sat in chair. GM went to leave again and patient 'threw a fit,' he hit Psych Tech #1, was kicking, screaming and cursing. At that time a manual restraint occurred due to safety issues. Patient was squirming, moving, trying to bite staff and continued to kick and yell. Within a few minutes patient was able to walk into quite room where he received medication."

Further review of the complaint/grievance investigation documentation revealed Nurse #3 conducted an interview with Nurse #1 on 02/04/2011 at 1441. Review revealed "Reports saw patient push GM and getting loud. She went to get prn po (as needed by mouth) medication (Thorazine). When she returned to peds secure lobby, manual RI was in place due to patient trying to bite, kicking, and hitting. She reports nothing was over his face. She reports went back into work station to get order for IM medication and (Nurse #2 name) was then present. Reports patient walked to quiet room on own and received medication. Reports never saw face restricted. Reports hands on either side of head (at ears) to prevent biting. She reports seeing nothing inappropriate from staff."

Further review of the complaint/grievance investigation documentation revealed no available documentation Nurse #3 interviewed Psych Tech #2 regarding the RI involving Patient #6 on 01/29/2011 as of 02/09/2011.

Interview on 02/09/2011 at 1200 with the hospital's CPI (Crisis Prevention Intervention) Master Instructor (#1) revealed, CPI is the approved curriculum taught to hospital staff involved in the application of restrictive interventions. Interview revealed CPI teaches approved and appropriate techniques for the application of manual restraints. Interview revealed staff do receive training upon hire and annually thereafter. Interview revealed patients can be restrained in a prone (face down) position on their stomach when using the appropriate CPI technique. Interview revealed CPI has only one (1) approved technique for floor restraint called the CPI Team Control Position "Emergency Floor Procedure" where the patient is on the floor on his/her stomach and is manually restrained and assisted up off of the floor. Interview revealed the Emergency Floor Procedure requires two staff members to perform. Interview revealed it is not appropriate for one staff member to perform a floor restraint.

Review on 02/09/2011 of the CPI training material (dated 2006-2007) presented, revealed the CPI Team Control Position "Emergency Floor Procedure" for manual restraint is a two person procedure used on an individual who is on their stomach. Review revealed "Remember: The floor is a dangerous place to be when restraining someone. It should always be viewed as an interim position, with a goal of returning the person to the CPI Team Control Position as soon as possible ....If the acting-out person falls or drops to the floor, or is injuring himself on the floor, always consider the option of disengaging. If the person is not a danger to self or others while on the floor, staff may make the decision to move away and give a clear directive. If the team decides that disengaging is not a safe alternative and the individual is on the floor: Step 1 is to Position yourself seated and to the side of the individual (one person on each side of the individual). Continue to maintain control of the person's arms by securing them to your hip area. Your forearm (free arm) is positioned in front of the individual's shoulder. This minimizes any pressure being placed on the back. Note: the weight of each staff member is distributed among hips, legs, and forearms. Their weight is not resting on the person being restrained. Close body contact is designed to limit, but not totally prevent, mobility. Allowing the person to move his hips, chest, and abdomen also allows the individual to breathe more freely. To reduce the risk of positional asphyxia, be sure that you do NOT hold the person's legs, lean on the person's back, or put pressure on the shoulders. Step 2 Place the person's hands on the floor as you move to your hands and knees while maintaining close body contact. Ensure that the person's arms are placed wider than the shoulders so that he cannot generate too much leverage. Step 3 Allow the person to raise himself off the floor. Step 4 Bring your inside arm behind and under the person's arms using the crux of the elbow to provide support. Raise your inside leg in preparation for standing. Step 5 Maintain close body contact as you move up and forward at a 45-degree angle. As the person moves to his feet, you can place the person in either the CPI Team control Position or the CPI Transport Position."

Observation on 02/09/2011 at 1740 of a return demonstration provided by Psych Tech #1 and Psych Tech #2 with the assistance of another staff member (who played the role of Patient #6) demonstrated how they applied the manual restraint to Patient #6 on 01/29/2011 at 1245. Observation revealed the patient was initially on the floor supine, kicking, and waving arms. Further observation revealed Psych Tech #1 was attempting to hold the patient's legs down to the floor (from the distal feet location, not from the sides of the patient's legs) while the patient was supine in order to prevent kicking. Observation revealed Psych Tech #1 was holding the patient around the ankles to mid-calf location. Further observation revealed the patient's arms, head, and torso were not restrained and able to move freely. Further observation revealed Psych Tech #2 entered the area to assist. Observation revealed as Psych Tech #1 continued to hold the patient's legs down (with no change in technique or location) when the patient abruptly "flipped" over onto the stomach (face-down). Observation revealed Psych Tech #1 continued to hold the patients feet (with no change in technique or location). Further observation revealed Psych Tech #2 approached the patient from the patient's left side and grabbed the patient's left arm and placed it into a stretched out secured position with the left shoulder held to the floor. Observation revealed the patients head and right arm were still able to move freely. Further observation revealed Psych Tech #2 reached across the patient while immobilizing the left arm and grabbed the right arm and placed them both up under the patient's chest in a crossed position. Observation revealed the two psychiatric technicians then lifted the patient up off the floor in order to carry the patient to the quiet room. Observation revealed Psych Tech #2 carried the upper torso and Psych Tech #1 carried the lower torso/legs. Interview immediately after the observation with Psych Tech #1 and #2 revealed the demonstration to be an accurate portrayal of the RI used on Patient #6 on 01/29/2011 at 1245.

Note: Prior to the start of the demonstration the two Psychiatric Technicians were given instructions by the Surveyor to describe in detail to the staff member playing the role of Patient #6 the behaviors displayed by the patient during the restrictive intervention. The demonstration was conducted with hospital nursing unit management staff, administrative management staff, and CPI Master Instructors present.

Interview on 02/09/2011 at 1750 with the unit nurse manager (a former CPI Master Instructor #2), CPI Master Instructor #1, and administrative management staff present during the return demonstration by Psych Tech #1 and #2 revealed the two staff members failed to perform appropriate and approved restraint techniques. Interview revealed they did not perform the Emergency Floor Procedure appropriately, by holding the patient's feet down and not being in an appropriate position to protect the patient head. Interview revealed if the staff members performed the procedure appropriately they would have been able to have some control over the patient's head movements thus possibly preventing rug burns and abrasions to the head and face. Further interview confirmed the two psychiatric technicians failed to implement restraints in accordance with safe and appropriate restraint techniques resulting in an injury to Patient #6 on 01/29/2010. Interview revealed "the two psychiatric technicians needed to have a refresher in appropriate restraint techniques." Interview further revealed no new education or training had been provided nor monitoring conducted for the two psychiatric technicians nor other staff members involved in the use of restraint/seclusion since the incident on 01/29/2011.

Telephone interview on 02/09/2011 at 1230 with Nurse #2 revealed she was on duty the day Patient #6 was placed in a RI on 01/29/2011. Interview revealed Psych Tech #1 and #2 were placing the patient into a RI. Interview revealed she was "just observing." Interview revealed the patient was lying on his stomach with his head held up. Interview revealed she went to get the security guard. Interview revealed she was not sure of what the security guard did during the RI. Interview revealed she does not use the floor restraint as much as other RI techniques. Interview revealed after the RI was discontinued she noted Patient #6 had abrasions to his forehead, and one arm. Interview revealed she notified Physician A and the physician examined the patient.

Telephone interview on 02/09/2011 at 1250 with Nurse #1 revealed she was on duty the day Patient #6 was placed in a RI on 01/29/2011. Interview revealed she first saw the patient becoming aggressive and went to get a PRN medication. Interview revealed when she returned the patient was being manually restrained by Psych Tech #1 and #2. Interview revealed the patient was on his back and one tech was holding the patients head and the other technician was holding the arms and body of the patient. Interview revealed the RI lasted 5-10 minutes. Interview revealed the patient was moved to the quiet room from the lobby then given Thorazine.

Telephone interview with Psych Tech #2 on 02/09/2011 at 1320 revealed he was on duty when Patient #6 was placed into a RI on 01/29/2011. Interview revealed he had stepped into the peds (pediatric) secure lobby to help Psych Tech #1 who was holding Patient #6's feet to keep him from kicking. Interview revealed Patient #6 was on the floor squirming around. Interview revealed himself and Psych Tech #1 were trying to control the patient. The patient then flipped over onto his stomach (face-down). Interview revealed he was in front of the patient trying to stop him from swinging his arms and biting. Interview revealed the other staff member (Psych Tech #1) was holding the patient's legs. Interview revealed two nurses (Nurse #1 and #2) were present but did not participate in the RI.

Interview with Psych Tech #1 on 02/09/2011 at 1517, revealed Patient #6 was becoming agitated and aggressive, kicking and screaming when he thought his grandmother was going to leave. The patient had been sitting in a wooden chair at a table, with his grandmother present. He "flopped" himself to the floor and the staff attempted to get the patient back into his seat without success. Interview revealed the patient ended up on his back initially then turned himself onto his stomach (face-down). Interview revealed Psych Tech #1 got hold of the patient's feet to control the kicking and Psych Tech #2 was attempting to control the patient's arms. Interview revealed Psych Tech #1 indicated this all took place with-in a 2 to 3 minute time frame. Interview revealed two nurses (Nurse #1 and #2) came into the area 1-2 minutes later and instructed them to move the patient to the quiet room. Further interview revealed the two psychiatric technicians then picked the patient up off the floor, by one picking up the feet (Psych Tech #1) and the other picking up the patient's upper torso (Psych Tech #2). Interview revealed the patient was in a face-down position, carrying the patient to the quiet room. Interview revealed the patient was administered an injection by the nurse (Thorazine 50 milligrams Intramuscular).

Review on 02/10/2010 of staffing schedules for 01/29/2011 to 02/10/2011, revealed Psych Tech #1 staffed shifts on 01/30, 01/31, 02/01, 02/02, 02/03, 02/05, 02/06, 02/07, 02/08, and 02/09/2011 and Psych Tech #2 worked on 01/30, 02/02, 02/05, 02/06, and 02/09/11 without any re-education or refresher training in appropriate CPI techniques.

Review of the Personnel File for Psych Tech #1 revealed his current CPI training expires on 06/23/2011.

Review of the Personnel File for Psych Tech #2 revealed his current CPI training expires on 06/23/2011.
VIOLATION: GOVERNING BODY Tag No: A0043
Based on policy and procedure reviews, open and closed medical record reviews, incident report reviews, grievance file reviews, restraint/seclusion education training material reviews, observations of a staff return demonstration, staffing schedule reviews, personnel file reviews, and staff interviews, the hospital failed to have an effective Governing Body to ensure: a safe environment for patients; delivery of safe patient care; promotion of patient's rights; and to ensure adequate nursing supervision.

The finding include:

1. The hospital's nursing staff failed to protect and promote patient's rights for a safe environment as evidenced by failing to implement restraints in accordance with safe and appropriate restraint techniques resulting in a patient injury for 1 of 1 patients sampled that was injured during a restraint (#6).

~cross refer to 482.13 Patients' Rights, Condition Tag A0115.

2. The hospital's nursing staff failed to have an effective nursing service providing oversight of day to day operations by failing to ensure nursing staff implemented restraints in accordance with safe and appropriate restraint techniques.

~cross refer to 482.23 Nursing Services, Condition Tag A0385.