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.
| JEWISH HOSPITAL & ST MARY'S HEALTHCARE | 200 ABRAHAM FLEXNER WAY LOUISVILLE, KY 40202 | March 12, 2018 |
| VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION | Tag No: A0162 | |
| Based on observation, interview, record review, video surveillance review, and review of the facility's policies, it was determined the facility failed to ensure staff did not force patients to take a time-out for non-violent behaviors in an area they could not leave until calm for one (1) of ten (10) sampled patients, Patient #1. Patient #1 became upset because he/she did not earn the special reward snack for good behavior and started screaming in the dayroom. Per interviews with staff, the patient was not threatening and was not a harm to self or others; however, staff requested the patient take a time-out and the patient refused. Video footage revealed staff forced the patient from the chair he/she sat in, grabbed the patient under the armpits, and took the patient to his/her room for a time-out. The findings include: Review of the facility's policy, Patient Rights, dated December 2016, revealed patients had the right to be free from restraint and seclusion of any form that were not necessary or were used as a means of coercion, discipline, convenience, or retaliation by staff. Review of the facility's Restraint and Seclusion policy, dated March 2017, revealed the facility focused on protecting and preserving patient rights, dignity, and well-being during the use of restraints in accordance with a written modification to the patient's plan of care. The facility would promote the safe application and removal of restraint and seclusion by competent staff. A physical restraint was any manual method or mechanical device, material, or equipment that immobilized or reduced the ability of a patient to move his/her arms, legs, body, or head freely, which included any therapeutic Safe Crisis Management (SCM) physical holding. Restraints would not be used as punishment, for convenience of staff, or response to behaviors or circumstances that did not constitute a danger of injury to the patient or others. Restraint use was limited to situations where there was appropriate clinical justification based on a comprehensive assessment of the patient. Restraint for management of violent or self-destructive behavior would only be used in emergency situations to ensure the patient's safety and less restrictive interventions were ineffective. An emergency situation was defined as a situation where the patient's behavior was violent or aggressive and where behavior presented an immediate and serious danger to the safety of the patient, others, and staff. Review of the facility's Safe Crisis Management (SCM) Instructor Manual, dated 2015, revealed the use of emergency safety physical intervention referred to the application of force that restricted a patient's mobility/movement. Types of Emergency Safety Interventions staff would implement included time-outs, seclusion, and restraints. A time-out was a teaching strategy where patients could learn to calm themselves while not participating in current routine or activity. Seclusion was the placement of a patient against their will in a designated room. A physical, mechanical, and or chemical restraint could also be implemented. A physical restraint was the application of physical force by one (1) or more individuals that reduced or restricted the ability of the patient to move his/her arms, legs, or head freely. The level of force that could be used in these circumstances was governed by the principle of the least restrictive alternative, which meant the intervention must be employed in the least amount necessary to ensure a safe outcome. The use of excessive force was a violation of social policy and legal principals. Further review of the SCM Manual revealed a SCM hold to assist a patient from a supine position would take two (2) staff and they should communicate with one another and use coordinated movements. Each staff would move to a kneeling position and hold the patient forearms near the wrist and then with the inside of their other hand would scoop underneath the patient's armpit and end with their palms up on the patients shoulder blade. Staff would slide the patient's forearms across until the forearms were between the staff's inside elbows and inside hips. Staff should sit the patient up into a seated/kneeling position then to standing. An SCM technique to escort a patient short distances included the Extended Arm Assist technique. Staff would stand to the right of the patient and place their left hand on the patient's shoulder blade or grasp their shirt and with the right hand secure the patient's right arm slightly above the elbow. The staff member should be positioned slightly behind the patient and to the outside. Another SCM technique to transport patients, called a Hook and Carry, would require two (2) staff members and they would hold the patient at the wrist and place their other arm under to where their elbow would rest in the patient's armpit. Staff would then perform a rocking motion to interrupt the patient's balance in order to transport quickly before the patient could regain their balance. Seclusion was the placement of an individual against his/her will in a designated room. While in the room, egress was restricted. Seclusion was used to intervene in dangerous behavior and provided external controls for the individual whose internal control was overwhelmed. Review of the Three (3) South Behavior Protocol, not dated, revealed the protocol directed staff to follow the procedures listed in the Protocol if a patient engaged in any of the following behaviors: pacing, verbal disruption such as cursing, yelling, making threats, or performing minor property destruction. If a patient engaged in any of these behaviors, the employee should immediately ask the patient if he/she would like to use one of the appropriate anger management strategies. The staff member should have the patient use the strategies in any area, which was safe and away from other patients. The strategies to offer were taking a self-time-out, talking to adults about what was bothering him/her, ignoring and/or walking away from others that were bothering him/her, asking for help when he/she was prompted to do something difficult or that he/she did not know how to do. When implementing the time-out procedure, staff should not provide any unnecessary attention of any kind, which included verbal reprimands, talking in a raised voice, showing emotional facial expressions, making eye contact, talking about marking the patients flow tracker, or arguing with the patient. The employee should use a timer for the time-out process. If the patient engaged in repeated property destruction or any physical aggression, the employee would prompt the patient to go to an area away from others to take a five (5) minute time-out, which may be in the hallway, quiet room, or the other side of the day room. If the patient did not walk within ten (10) seconds of prompting, the employee would either physically help the patient to the time-out area or call a code for help. Once the time-out procedures had started, the patient should not be allowed to escape from having to take a time-out. Once the patient remained in the time-out area, the employee should tell the patient "I will start your time-out as soon as you are calm." The employee should hold the timer where the patient could see it and set the timer for five (5) minutes. If the patient left the time-out area, the employee should redirect the patient back to the area and continue to do that as many times as necessary. If the patient repeatedly left the time-out area and/or displayed repeated physical aggression towards others, the employee should contact the Registered Nurse and place the patient in a safe crisis management hold until the patient complied with the time-out request. Record review revealed the facility admitted Patient #1 on 12/21/17, with diagnoses of Mild Mental Retardation, Disruptive Behavior Disorder, and history of Sexual Abuse. The patient was thirteen (13) years old with a recent history of suicidal threats and auditory hallucinations. Observation of Patient #1, on 02/28/18 at 3:20 PM, revealed the patient was in the Kid Zone participating in a group activity. Review of Patient #1's Physician Progress Note, dated 01/12/18 at 5:29 PM, revealed the physician visited with the patient and reviewed his/her medical record. The physician noted the patient was compliant with care and avoided any major displays of disruptive behavior, but continued to be mildly irritable. Continued review of the clinical record revealed nursing staff noted on 01/13/18 at 9:22 PM, Patient #1 reported to his/her mother staff scratched him/her under both arms during a SCM hold on 01/12/18. However, the clinical record did not reveal documentation of a physician's order to place the patient in a hold on 01/12/18, nor did nursing staff note an assessment of the patient while in or after the SCM hold. In addition, staff did not perform a face-to-face assessment within one (1) hour of the hold. Review of pictures taken of Patient #1 on 01/13/18 at 9:05 PM, revealed there were several red/pink scratch marks in both armpits and the surrounding skin had a darker red to pink discoloration. A photograph of the patient's neck also revealed a red scratch. Interview with Patient #1, on 02/28/18 at 3:20 PM, revealed Mental Health Worker (MHW) #1 grabbed him/her under the arms and around the neck and it hurt. The patient stated MHW #2 pulled him/her by the arm to get him/her out of a chair. The patient stated the treatment provided by MHW #1 and #2 made him/her feel sad. The patient stated MHW #1 took him/her to his/her room, which made him/her upset and he/she went off. Review of Video Surveillance Footage, dated 01/12/18 and timed 7:58 PM, revealed Patient #1 seated in the dayroom with other patients and staff. Patients were not violently acting out or being physically aggressive requiring staff intervention. MHW #2 walked over to the seated Patient #1 and placed her hands on the patient's right hand and shoulder, and then pulled Patient #1 out of the chair by the right arm. The patient dropped to the floor attempting to get out of MHW #2's grasp. Further video review revealed MHW #2 bent over to pull the patient up off the floor by placing her hands under the patient's armpits. The hallway camera view revealed MHW #2 continued to attempt to pull Patient #1 up off the floor with difficulty while the patient wiggled around on the floor trying to prevent staff from picking him/her up. The hallway camera view revealed MHW #1 got up out of his chair and walked over to Patient #1 and bent over to assist MHW #2 with picking the patient up off the floor. MHW #1 pulled the patient up off the floor from behind by placing his hands in the armpits of the patient. Once Patient #1 was up off the floor, MHW #1 pulled up on the patient's armpits causing the patients elbows to be at ear level. While remaining behind the patient, MHW #1 kept his hands in Patient #1's armpits and quickly rushed the patient down the hall towards the patient's room. MHW #1 than released the patient from his grasp while he unlocked the patient's door. The hallway camera view revealed the patient entered his/her room once the door was open, then the door closed behind the patient, but did not shut completely. Immediately, MHW #1 entered the room, a few seconds passed, and MHW #1 exited the patient's room. Patient #1's door closed again and then MHW #1 went back into the room. The camera view from inside Patient #1's room revealed the patient was seated on his/her bed and MHW #1 entered the room and bent down and got his/her face within inches of the patient's face. The video did not have audio; however, a conversation between the patient and MHW #1 was observed and the patient exhibited upset facial expressions and body language. MHW #1 then left the room and Patient #1 started tearing up his/her glasses. Interview with Registered Nurse (RN) #1, on 02/22/18 at 2:13 PM, revealed Patient #1's mother complained to staff on 01/13/18, regarding bruising and scratches she found in the patient's armpits and a scratch on the neck. She stated she photographed the patient's neck and both armpits and reported the mother's concerns to the House Manager. According to RN #1, she did not receive a report from off going staff that the patient had been in a recent hold or that Patient #1 had sustained scratches or bruising during the hold. She stated she was not sure how the injuries happened. Interview with the House Manager, on 02/23/18 at 8:12 AM, revealed she received a report from Patient #1's mother regarding bruising to the patient's armpits. She stated she assessed the resident's underarms and witnessed the bruises and scratches. Interview with MHW #2, on 02/22/18 at 2:00 PM, revealed on 01/12/18 around 8:00 PM, Patient #1 became upset because he/she did not earn the special reward snack for good behavior that shift. She stated the patient was seated in the dayroom when he/she started screaming and disrupting the milieu. MHW #2 stated the patient did not make any threats and was not a harm to self or others. She stated she was concerned the screaming could cause the other patient's in the dayroom to react so she requested the patient take a time-out and the patient refused. MHW #2 stated after the patient refused to take a time-out, she reached for the patient's arm to do a SCM technique called an extended arm to get the patient out of the chair and to an area for a time-out. Once she got the patient out of the chair, the patient dropped to the floor. MHW #2 revealed she made several attempts to pull the patient up off of the floor but was unsuccessful and MHW #1 came over and pulled the patient up off the floor and took the patient to his/her room for a time-out. Interview with MHW #1, on 02/23/18 at 10:55 AM, revealed on 01/12/18 at about 8:00 PM, staff gave out snacks and rewards for good behavior. He stated staff gave out snacks and Patient #1 received his/he snack but got upset because he/she did not receive the reward snack. MHW#1 stated the patient was yelling and disrupting the milieu so MHW #2 verbally prompted the patient to take a time-out and the patient refused. Then MHW #2 performed a touch prompt and the patient went down to the floor. MHW #1 stated if staff initiated a touch prompt and the patient did not comply with the requested time-out, staff would physically escort the patient to the time-out area. MHW #1 stated he alone got the patient up off the floor using a Hook and Carry technique then transferred the patient to his/her room for the time-out procedure. According to MHW #1, after the patient entered his/her room he/she began to perform property destruction by slamming the door so he went back into the room, got down in the patient's face, and told the patient he/she would get another mark off on his/her flowsheet making it harder to earn the snack reward. He stated he did not inform the nurse about the forced time-out or restraint hold used on Patient #1 because he thought the nurse witnessed them as he and the patient walked through the unit. Interview with RN #2, on 02/23/18 at 11:15 AM, revealed neither MHW #1 nor #2 reported to him they had laid hands on the patient in order to restrain or that the patient had refused a time-out. He stated he did see MHW #1 escorting Patient #1 down the hall; however, he could not see any behavior from where he was in the hallway that he considered inappropriate. He stated staff was not to force patients to take a time-out and if the staff forced a time-out, it was considered a seclusion requiring a physician order. Interview with the Unit Manager (UM), on 02/22/18 at 9:30 AM, revealed she viewed the video footage of staff interaction with Patient #1 on 01/12/18, to determine what happened and noted MHW #2 prompted the patient out of the chair and did not see anything concerning with the interaction. She stated she viewed the footage of MHW #1 escorting the patient to his/her room and did not see anything on the video concerning. However, the UM stated putting hands on patients should be the last resort and staff should use the least restrictive intervention first. The UM stated physically forcing a patient to take a time-out was not hospital policy. She stated staff could have removed the other patients from the area if they thought Patient #1's behavior was escalating after he/she did not want to take a self-time-out. She stated she did not provide staff with formal training after the incident to re-educate staff on approved restraint use policy and procedures or to reiterate that the time-out process was voluntary for patients. Interview with the Director of Nursing (DON), on 03/09/18 at 3:15 PM, revealed the video footage was reviewed and it was determined MHW #1 used a non-traditional intervention with Patient #1 after the patient refused to take a time-out. She stated the facility retrained MHW #1 on SCM; however, did not identify the need to re-educate MHW #2 or nursing staff regarding time-outs or SCM and seclusion procedures. Interview with the Chief Nursing Officer (CNO) and the Chief Executive Officer (CEO), on 03/09/18 at 4:15 PM, revealed their role was to provide oversight and direction. Each stated they were ultimately responsible for the care and services delivered by staff. The CNO stated he reviewed the video of the incident with Patient #1 and determined MHW #1 used a non-standard intervention with Patient #1. He stated the facility routinely provided monthly, quarterly, and yearly training on SCM and time-out procedures. However, after identifying a non-standard intervention was used on Patient #1, neither the CNO nor the CEO directed leaders to provide staff with immediate re-education on the appropriate use of time-out, SCM, or seclusion procedures. |
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| VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION | Tag No: A0166 | |
| Based on observation, interview, record review, and review of the facility's policy, it was determine the facility failed to ensure patients' treatment plans were revised after an episode of seclusion and restraint (S&R) for six (6) of ten (10) sampled patients, Patient #1, #3, #4, #5, #8, and #9. The findings include: Review of the facility's Treatment Planning Policy, dated May 2015, revealed the purpose of treatment planning was to determine the needs, assets, and liabilities of each patient. The team would insure uniformity of the short and long-term goals and continuity of care. The team would also evaluate the effectiveness of the treatment plan and its later modifications. The policy stated each patient would have a documented individualized treatment plan developed by the interdisciplinary team in a timely manner. In addition, the team would confer as often as needed to develop and/or revise plans for patient care. 1. Review of Patient #1's clinical record revealed the facility admitted Patient #1 on 12/21/17, with diagnoses of Mild Mental Retardation, Disruptive Behavior Disorder, and History of Sexual Abuse. The patient had recent history of suicidal threats and auditory hallucinations. Observation of Patient #1, on 02/28/18 at 3:20 PM, revealed the patient was in the Kid Zone participating in a group activity. Interview with Mental Health Worker (MHW) #2, on 02/22/18 at 2:00 PM, revealed on 01/12/18 around 8:00 PM, Patient #1 became upset because he/she did not earn the special reward snack for good behavior that shift. She stated the patient was seated in the dayroom when he/she started screaming and disrupting the milieu. MHW #2 stated the patient did not make any threats and was not harm to self or others. She stated she was concerned the screaming could cause the other patients in the dayroom to react so she requested the patient take a time-out and the patient refused. After the patient refused to take a time-out, she stated she reached for the patient's arm to get the patient out of the chair and to an area for a time-out. Once she got the patient out of the chair, the patient dropped to the floor. MHW #2 stated she attempted several times to pull the patient up off the floor but was unsuccessful so MHW #1 came over, pulled the patient up off the floor, and took the patient to his/her room for a time-out. MHW #2 stated she had not received re-education on treatment interventions for Patient #1 or approved unit Behavioral Protocols. MHW #2 would not answer any further questions regarding how she would help a patient with coping skills. Review of Patient #1's Treatment Plan, dated 02/20/18, revealed the goal was for the patient to participate in 100 % of his/her treatment programing. The interventions instructed staff to reinforce coping skills such as have the patient talk with staff when angry and take a self-time-out. However, nursing staff did not revise the plan after the patient exhibited behaviors of screaming on 01/12/18 and/or after staff physically forced the patient to take a time-out. Interview with Registered Nurse (RN) #2, on 02/23/18 at 11:15 AM, revealed the patient's treatment plan directed patient care. He stated after a S&R incident, nursing staff would document the incident on a S&R Event Note and he thought the treatment plan was revised with interventions automatically after staff put in the event note. However, after he reviewed the treatment plan with the surveyor, RN #2 stated Patient #1's treatment plan was not automatically updated. He stated nursing staff met weekly to discuss the treatment plan; however, Patient #1's treatment plan had not been revised with interventions related to the patient's behavior of screaming after not receiving his/her reward snack on 01/12/18, or with additional interventions for staff to follow before placing hands on the patient. Interview with the 3 South Unit Manager (UM), on 02/22/18 at 9:30 AM, revealed the treatment plan directed the care of the patient. She stated the computer system automatically updated the treatment plan with interventions after a nurse documented a S&R Event Note. However, after discussing Patient #1's treatment plan with the UM, it was determined the UM was not aware the computer did not automatically revise the treatment plan with interventions after nursing documented a S&R Event Note. She stated if nursing did not revise the treatment plan with additional interventions after a S&R episode, staff potentially would not receive the necessary information to respond accordingly to the patient's behaviors. 2. Review of the clinical record for Patient #3 revealed the facility admitted the patient on 02/13/18, with diagnoses of Mood Disorder, Disruptive Behavior Disorder, and Oppositional Defiant Disorder. The patient also had Attention Deficit Hyperactivity Disorder and a note to Rule out Post Traumatic Stress Syndrome. Review of the Psychiatric Assessment, dated 02/13/18, revealed the patient had significant behavioral issues and apparently witnessed domestic violence at home between his/her parents and he/she tried to defend his/her mother. Review of Patient #3's S&R Orders, dated 02/15/18, 02/16/18, and 02/21/18, revealed staff placed the patient in S&R because he/she was a danger to himself/herself or others. Review of the Seclusion and Event Note, dated 02/15/18 and timed 2:32 PM, revealed staff placed Patient #3 in multi person Hook and Carry SCM hold after the patient became upset with a game controller. Staff requested the patient take a time-out and walked the patient to the time-out room. On the way to the time-out room, the patient changed his/her mind and refused to take a time-out. Staff touch prompted the patient to continue to the time-out room and the patient hit staff. After hitting staff, several staff placed the patient in a hold and took the patient to the time-out room. The patient's behaviors continued to escalate and staff placed the patient in five (5) point restraints. Review of the S&R Event Note, dated 02/15/18 at 6:02 PM, revealed, Patient #3 took a deck of cards from a peer, ran down the hall, pushed staff, and became combative. Staff placed Patient #3 in a Seated Cradle and Supine Torso hold, then put him/her on a stretcher and transferred to the time-out room. The patient remained restrained until calm. Nursing staff documented in the Event Note, staff could have handled the situation differently by using more limit setting, decreasing stimuli, or modifying the environment. However, these interventions were not transferred to the patient's treatment plan, initiated on 02/13/18. Review of the S&R Event Note, dated 02/21/18 and timed 3:10 PM, revealed Patient #3 became agitated and taunted peers. Staff asked the patient to take a time-out and the patient refused; staff touch prompted the patient to take the time-out in the quiet room and the patient became aggressive with staff. Staff placed the patient in five (5) point restraints. Further review of the Note revealed nursing staff documented what staff could have done differently to avoid S&R, which was to decrease environmental stimuli, identify more expectations, and/or apply more redirection. Continued review revealed nursing staff marked yes to the question regarding whether the treatment plan was revised based on the event. However, review of the treatment plan revealed those identified interventions, which staff could have used to handle the situation differently, were not added to the treatment plan. Review of Patient #3's Treatment Plan, initiated on 02/13/18, revealed the discharge goals was to meet program expectations and no longer engage in aggressive or defiant behavior. The interventions stated staff would provide psychotherapy, assess patient and family towards goals, and de-escalate/debrief emotionally charged behavior. Further review of the treatment plan revealed on the last page of the plan was a box titled additional interventions. The additional interventions did not have a related goal but had a date next to each one listed. The interventions dated 02/13/18, stated possible therapeutic interventions were for staff to individualize SCM as indicated, assign groups with awareness of patient relationships, restrict use of, limiting access to, and or re-introduce objects that could cause harm to others. Under additional interventions, dated 02/15/18, the treatment plan stated S&R, assess, monitor, and release. Interview with RN #3, on 02/28/18 at 9:40 AM, revealed additional interventions listed for S&R were auto-populated from the Event Note and indicated the patient had been placed in S&R on 02/15/18. RN #3 stated assess, monitor, and release interventions were specifically related to the S&R process and not interventions for staff to implement to prevent further S&R. Further review of Patient #3's Treatment Plan revealed after each episode of S&R on 02/15/18, 02/16/18, and 02/21/18, nursing staff did not revise the treatment plan with interventions that directed staff in how to address the patient's behaviors in order to reduce or eliminate the need to use S&R with Patient #3. Review of the Treatment Planning Update Form, dated 02/22/18, revealed the treatment team met and discussed the patient's behavior. The document noted the patient continued to show aggression and staff placed the patient in restraints on 02/21/18, for throwing a banana and a pencil. The form stated the team discussed actions taken after the S&R. However, the form lacked evidence to show the treatment team had revised the plan with interventions related to each documented episode of S&R. Continued interview with RN #3, on 02/28/18 at 9:40 AM, revealed after each episode of S&R, nursing staff completed an electronic S&R Event Note. He stated at the end of the electronic note there was a question that required a yes or no answer regarding whether the treatment plan was updated or not after a S&R episode. RN #3 stated he always clicked yes because he thought the information in the event note auto populated over to the electronic treatment plan, which to him meant nursing staff had revised the treatment plan. RN#3 reviewed Patient #3's treatment plan with the surveyor and clarified the treatment plan had not been updated with interventions to reduce or prevent further S&R after each episode on 02/15/18, 02/16/18, and 02/21/18. He revealed it was important for patient treatment plans to be revised with interventions that directed staff in the care of the patient, otherwise patient behavioral care needs would not be met. 3. Review of the clinical record for Patient #4 revealed the facility admitted the patient on 02/14/18, with a diagnosis of Disruptive Behavior Disorder. Review of a S&R Event Note, dated 02/14/18, revealed the grandmother brought the patient to the facility for admission and the patient ran once they arrived and staff followed and placed the patient in several S&R holds and then transitioned to five (5) point restraints. Review of a S&R Event Note, dated 02/18/18, revealed nursing staff documented staff kicked the patient out of the social workers group multiple times and the patient refused to go to the time-out room despite multiple requests. Staff used proximity control but the patient still refused to go to the time-out room. Staff performed a touch prompt and the patient attempted to hit staff and kick a male staff in the genitals. Staff placed the patient in a SCM multi person Supine Torso hold and then released the patient once he/she was calm. Further review of the note revealed nursing staff documented what staff could have done differently to avoid S&R, which was for staff to apply more limit setting and proximity control. Nursing Staff marked yes to the question regarding whether the treatment plan was revised based on the event. However, review of the treatment plan revealed those identified interventions staff determine could have been used to avoid the use of S&R were not added to the treatment plan. Review of Patient #4's Treatment Plan, initiated 02/14/18, revealed a discharge goal for the patient to remain free of aggression through the implementation of learned coping skills. The interventions directed staff to meet weekly to review the patient's progress or barriers to treatment. There was a goal for the patient to have decreased episodes of violent behavior from two (2) to zero (0) per week by discharge. The interventions directed staff to use de-escalation techniques and debrief with the patient after emotionally charged behavior. Further review revealed on the last page of the Treatment Plan was a list of possible therapeutic interventions for aggressive assaultive behavior. The interventions stated to individualize per patient the use of SCM as indicated, assign groups with awareness of patient relationships, and restrict use of, limit access to, and or re-introduce objects that could cause harm to others. At the end of this area of the treatment plan was a note dated 02/18/18, regarding S&R implementation of a supine torso hold times five (5) minutes for attacking staff, which started at 2:59 PM. However, there was no documented interventions for staff to implement related to this noted use of S&R. Review of Patient #4's Treatment Planning Update Form, dated 02/20/18, revealed the patient continued to need multiple redirections and to work on coping skills. However, the treatment team did not revise the treatment plan with additional interventions to direct staff in how to help the patient work on coping skills or to better comply with redirection. Nor did the treatment team add interventions to help staff avoid the use of S&R with Patient #4. Interview with RN #3, on 02/28/18 at 9:40 AM, revealed upon admission, Patient #4's initial treatment plan was developed with interventions related to aggression and difficulty with authority He stated when a S&R Event Note was completed, he thought the computerized electronic medical record automatically updated the treatment plan with the information from the event note. He stated nursing staff was responsible for updating the patient's treatment plan and the plan directed the care of the patient. RN #3 stated if nursing staff did not revise the treatment plan, staff would not have the direction to deliver the necessary care and services. 4. Review of Patient #5's clinical record revealed the facility admitted the patient on 02/18/18, with the diagnosis of Anxiety Disorder. Review of the Psychiatric Assessment, dated 02/18/18, revealed the patient had a history of depression, anxiety, and cutting his/her arms repeatedly. Observation of Patient #5, on 02/22/18 at 1:35 PM, revealed the patient was in the dayroom on 2 Lourdes with two (2) staff present. Review of Patient #5's S&R Order, dated 02/19/18, revealed staff placed the patient in a SCM hold at 10:40 PM, due to the patient superficially scratching self, causing the patient to bleed. Review of a S&R Event Note, dated 02/19/18, revealed during safety rounds, staff observed Patient #5 superficially scratching his/her wrist with a ring and the patient had minor bleeding and used his/her blood to draw on the wall. Staff asked the patient to walk to the quiet room and for the patient to hand over the ring. The patient refused staff requests and would not contract for safety, and staff placed the patient in a SCM hold to remove the ring and then staff released the patient from the restraint. Further review of the S&R Event Note revealed what staff could have done differently to avoid S&R, which was for staff to acknowledge the patient's feelings, increase communication, provide more one to one time, and more limit setting. Nursing staff marked yes to the question regarding whether the treatment plan was revised based on the event. However, review of the treatment plan revealed those identified interventions staff determine could have been used to avoid the use of S&R were not added to the treatment plan. Review of Patient #5's Treatment Plan, initiated on 02/18/18, revealed a discharge goal for the patient to be able to verbalize feelings of Depression and identify three (3) triggers that contributed to suicidal thoughts. The interventions listed directed the Social Worker to meet with the patient weekly to discuss the patient's behaviors, treatment goals, and response to treatment. In addition, the treatment team would assist the patient in developing a safety plan and would monitor the environment. Further review revealed the team did not revise the plan with interventions to prevent another restraint or self-harming episode after the event on 02/19/18. Interview with RN #9 via telephone, on 03/09/18 at 12:38 PM, revealed nursing staff was responsible for revising the treatment plan after a S&R episode and she thought after nursing staff completed the S&R Event Note, the computer automatically updated the treatment plan with the Event Note information. She stated she was not aware the computer did not automatically revise the treatment plan with the interventions she documented in the event note regarding interventions the staff could have used to prevent the S&R from occurring for Patient #5. Interview with the 2 Lourdes Unit Manager, on 02/28/18 at 11:15 AM, revealed the treatment plan guided staff in the care of the patient and was automatically updated when nursing staff completed a S&R Event Note. She stated she was not aware the information nursing staff documented in the Event Note, related to what could have been done differently to avoid the S&R, did not automatically transfer over to the treatment plan. She stated nursing staff was ultimately responsible for updating the treatment plan initiated for Patient #5. 5. Review of Patient #8's clinical record revealed the facility admitted the patient on 02/05/18, with the diagnoses of Anxiety Disorder and Disruptive Behavior Disorder. The patient also had a history of abuse and neglect. Observation of Patient #8, on 02/22/18 at 1:40 PM, revealed the patient was sitting on the floor taking a break. Review of Patient #8's Treatment Plan, initiated 02/05/18, revealed the patient had a goal to decrease episodes of violent behavior from five (5) to zero (0) per week by the time of discharge. The plan directed staff to de-escalate/debrief emotionally charged patient behavior. In addition, there was a goal for the patient to verbalize and or demonstrate two (2) alternative strategies to use after each episode of behavioral acting out, such as taking a self time-out and counting backwards. The intervention directed staff to explore precursors to violent and charged behavior. Review of a S&R Event Note, dated 02/20/18, revealed Patient #8 was directed to take a time-out, refused, and when touched prompted the patient kicked staff and staff placed the patient in a multi person Carry Cradle hold and a Sitting Cradle hold. Nursing staff noted the patient was educated that aggression toward staff would not be tolerated. Further review of the note revealed nursing staff documented what staff could have done differently to avoid S&R, which was for staff to implement more limit setting. Nursing staff marked yes that the Treatment Plan updated. However, review of the Treatment Plan initiated 02/05/18, revealed the plan was not revised after the incident on 02/20/18. Review of a S&R note, dated 02/21/18, revealed Patient #8 was playing at bedtime with the roommate and was directed to take a time-out. Patient #8's behaviors continued to escalate, and the patient tried to hit staff and staff placed Patient #8 in a Seated Cradle hold until calm. Nursing staff noted again Patient #8 was educated that aggression towards staff would not be tolerated. Further review of the note revealed nursing staff documented what staff could have done differently to avoid S&R, which was to use different de-escalation techniques. Nursing staff marked yes to the question related to whether the treatment plan was updated or not. However, review of the Treatment Plan revealed nursing had not revised the plan after the incident on 02/21/18, to reflect the use of different de-escalation techniques. Interview with RN #6, on 02/27/18 at 9:27 AM, revealed nursing staff had to complete a S&R Event Note after a restraint hold and the electronic medical record automatically populated the information in the Event Note over to the Treatment Plan. He stated he did not revise the plan itself after an episode of S&R. Review of the Treatment Plan with RN #6 revealed the computerized electronic medical record did not automatically send the S&R Event Note information to the Treatment Plan. He stated the treatment plan directed the care of the patient and after a S&R, updated interventions would be beneficial for staff. 6. Review of Patient #9's clinical record revealed the facility admitted the patient on 02/12/18, with the diagnoses of Disruptive Mood Dysregulation Disorder, Autism Spectrum Disorder, and Receptive Expressive Language Disorder. Observation of Patient #9, in the 3 East Classroom, on 02/22/18 at 1:05 PM, revealed the patient was non-verbal and staff had the patient by the hand. Review of Patient #9's S&R Orders, dated 02/17/18, revealed staff placed the patient in S&R at 12:50 PM, 3:01 PM, and 3:57 PM. Review of a S&R Event Note, dated 02/17/18 and timed 12:50 PM, revealed Patient #9 threw a cup of water and then attempted to hit and bite staff and staff placed the patient in a multi person Seated Upper Torso hold for safety. The patient struggled during the hold but eventually calmed down and staff released the patient from the hold. Nursing staff listed behaviors staff could have used to handle the situation differently, which were for staff to be aware of body position, provide distraction, decrease environmental stimuli, increase communication, and provide more one to one time. Review of a S&R Event Note, dated 02/17/18 and timed 3:01 PM, revealed Patient #9 got very angry when he/she did not earn his/her reward snack and started screaming and slapping staff. Staff placed the patient in a SCM restraint hold and escorted in a SCM hold to the time-out room in order to take a time-out. The Event Note listed behaviors staff could have used to handle the situation differently and to avoid S&R, such as be aware of body position, provide distraction, decrease environmental stimuli, increase communication, and provide more one to one time. Review of a S&R Event Note, dated 02/17/18 and timed 3:57 PM, revealed Patient #9 started screaming, jumping on tables, and charging at staff and staff placed the patient in a SCM hold and the patient continued to fight with staff. Staff secluded the patient after the patient refused to comply. Nursing staff documented a list of behaviors staff could have used to handle the situation differently in order to avoid the S&R such as, be aware of body position, provide distraction, decrease environmental stimuli, increase communication, and provide more one to one time. Review of Patient #9's Treatment Plan initiated on 02/12/18, revealed a goal for the patient to have decreased aggression and property destruction. The interventions directed staff to assess patient and family progress towards stated goals and reinforce replacement behavior, which included following directions, accepting "no", and using pictures to communicate wants and needs to others. Further review revealed no documented evidence nursing staff revised or added the 02/17/18 S&R Event Notes' list of actions staff could have used to avoid S&R. Interview with RN #4, on 02/28/18 at 1:53 PM, revealed Patient #9 was low functioning, non-verbal, and only understood simple tasks. She stated nursing staff completed a S&R Event Note after each episode and in the electronic medical record there were drop down boxes she could select information from when she documented. RN #4 stated she had to document a yes or no to a question regarding whether the treatment plan was updated after the patient was placed in S&R and she always clicked yes because she thought the electronic medical record automatically updated the treatment plan with the information from the S&R Event Note. Review of Patient #9's Treatment Plan with RN #4 revealed the Plan had not been updated with the information from the S&R Event Note. She stated nursing staff was responsible for updating the Plan after a S&R event. Interview with the Director of Nursing (DON), on 03/09/18 at 3:15 PM, revealed the Treatment Plan directed the care of the patient and nursing staff was responsible for updating the plan. She stated each plan was automatically updated whenever a nurse documented a S&R Event Note. She stated she believed the facility was complaint with treatment plan revision after a S&R episode. However, review of Patient #1, #3, #4, #5, #8, and #9's Treatment Plans revealed the plans had not been revised after S&R episodes. Interview with the Chief Nursing Officer (CNO) and the Chief Executive Officer (CEO), on 03/09/18 at 4:15 PM, revealed their role was to provide oversight and direction. Each stated they were ultimately responsible for the care and services delivered by staff. The CNO and CEO stated the Treatment Plan was automatically revised with interventions after nursing staff completed a S&R Event Note. However, review of Patient #1, #3, #4, #5, #8, and #9's Treatment Plans revealed nursing staff did not update the plans, nor did the computer automatically add interventions from the S&R Event Notes to the electronic Treatment Plans to reduce the likelihood of another episode of S&R. |
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| VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION | Tag No: A0167 | |
| Based on observation, interview, record review, facility video review, and review of the facility's policies, it was determined the facility failed to ensure staff did not place patients in restraints or seclusion for non-violent behaviors for one (1) of ten (10) sampled patients, Patient #1. Patient #1 became upset because he/she did not earn a special reward snack for good behavior and started screaming in the dayroom; however, per staff interviews the patient was not threatening and was not a harm to self or others. Staff requested the patient take a time-out and the patient refused. Video footage revealed staff pulled Patient #1 out of the chair by the right arm, the patient dropped to the floor, and staff pulled the patient up off the floor from behind by placing hands in the patient's armpits. Once Patient #1 was up off the floor, staff pulled up on the patient's armpits causing the patients elbows to be at ear level. While remaining behind the patient, staff kept hands in Patient #1's armpits and quickly rushed the patient down the hall towards the patient's room. Per record review, after the incident, there were several red/pink scratch marks in both of the patient's armpits and the surrounding skin had a darker red to pink discoloration, in addition, the patient's neck had a red scratch. The findings include: Review of the facility's policy, Patient Rights, dated December 2016, revealed patients had the right to be free from restraint and seclusion of any form that were not necessary or were used as a means of coercion, discipline, convenience, or retaliation by staff. Review of the facility's Restraint and Seclusion policy, dated March 2017, revealed the facility promoted the safe application and removal of restraint and seclusion by competent staff. A physical restraint was any manual method or mechanical device, material or equipment that immobilized or reduced the ability of a patient to move his/her arms, legs, body, or head freely, which included any therapeutic Safe Crisis Management (SCM) physical holding. Restraints would not be used as punishment, for convenience of staff, or response to behaviors or circumstances that did not constitute a danger of injury to the patient or others. Restraint use was limited to situations where there was appropriate clinical justification based on a comprehensive assessment of the patient. Restraint for management of violent or self-destructive behavior would only be used in emergency situations to ensure the patient's safety and less restrictive interventions were ineffective. An emergency situation was defined as a situation where the patient's behavior was violent or aggressive and where behavior presented an immediate and serious danger to the safety of the patient, others, and staff. Review of the Safe Crisis Management (SCM) Instructor Manual, dated 2015, revealed the use of emergency safety physical intervention referred to the application of force that restricted a patient's mobility/movement. Types of Emergency Safety Interventions staff would implement included time-outs, seclusion, and restraints. A time-out was a teaching strategy where patients could learn to calm themselves while not participating in current routine or activity. Seclusion was the placement of a patient against their will in a designated room. A physical, mechanical, and/or chemical restraint could also be implemented. A physical restraint was the application of physical force by one (1) or more individuals that reduced or restricted the ability of the patient to move his/her arms, legs, or head freely. The level of force that could be used in these circumstances was governed by the principle of the least restrictive alternative, which meant the intervention must be employed in the least amount necessary to ensure a safe outcome. The use of excessive force was a violation of social policy and legal principals. Further review of the SCM Manual revealed a SCM hold to assist a patient from a supine position would take two (2) staff and they should communicate with one another and use coordinated movements. Each staff would move to a kneeling position and hold the patient forearms near the wrist and then with the inside of their other hand would scoop underneath the patient's armpit and end with their palms up on the patients shoulder blade. Staff would slide the patient's forearms across until the forearms were between the staff's inside elbows and inside hips. Staff should sit the patient up into a seated/kneeling position then to standing. An SCM technique to escort a patient short distances included the Extended Arm Assist technique. Staff would stand to the right of the patient and place their left hand on the patient's shoulder blade or grasp their shirt and with the right hand secure the patient's right arm slightly above the elbow. The staff member should be positioned slightly behind the patient and to the outside. Another SCM technique to transport patients called a Hook and Carry, required two (2) staff members and they would hold the patient at the wrist and place their other arm under to where their elbow would rest in the patient's armpit. Staff would then perform a rocking motion to interrupt the patient's balance in order to transport quickly before the patient could regain their balance. Seclusion was the placement of an individual, against his/her will, in a designated room. While in the room, egress was restricted. Seclusion was used to intervene in dangerous behavior and provided external controls for the individual whose internal control was overwhelmed. Review of the Three (3) South Behavior Protocol, not dated, revealed the protocol directed staff to follow the procedures listed in the Protocol if a patient engaged in any of the following behaviors: pacing, verbal disruption such as cursing, yelling, making threats, or performing minor property destruction. If a patient engaged in any of these behaviors, the employee should immediately ask the patient if he/she would like to use one of the appropriate anger management strategies. The staff member should have the patient use the strategies in any area, which was safe and away from other patients. The strategies to offer were taking a self-time-out, talking to adults about what was bothering him/her, ignoring and/or walking away from others that were bothering him/her, asking for help when he/she when prompted to do something difficult or that he/she did not know how to do. When implementing the time-out procedure, staff should not provide any unnecessary attention of any kind, which included verbal reprimands, talking in a raised voice, showing emotional facial expressions, making eye contact, talking about marking the patients flow tracker or arguing with the patient. The employee should use a timer for the time-out process. If the patient engaged in repeated property destruction or any physical aggression, the employee would prompt the patient to go to an area away from others to take a five (5) minute time-out, which may be in the hallway, quiet room, or the other side of the day room. If the patient did not walk within ten (10) seconds of prompting, the employee would either physically help the patient to the time-out area or call a code for help. Once the time-out procedures had started, the patient should not be allowed to escape from having to take a time-out. Once the patient remained in the time-out area, the employee should tell the patient "I will start your time-out as soon as you are calm." The employee should hold the timer where the patient could see it and set the timer for five (5) minutes. If the patient left the time-out area, the employee should redirect the patient back to the area and continue to do that as many times as necessary. If the patient repeatedly left the time-out area and/or displayed repeated physical aggression towards others, the employee should contact the Registered Nurse and place the patient in a safe crisis management hold until the patient complied with the time-out request. Record review revealed the facility admitted Patient #1 on 12/21/17, with diagnoses of Mild Mental Retardation, Disruptive Behavior Disorder and history of Sexual Abuse. The patient had recent history of suicidal threats and auditory hallucinations. Observation of Patient #1, on 02/28/18 at 3:20 PM, revealed the patient was in the Kid Zone participating in a group activity. Continued review of the clinical record revealed nursing staff noted on 01/13/18 at 9:22 PM, Patient #1 reported to his/her mother staff scratched him/her under both arms during a SCM hold on 01/12/18. However, the clinical record did not reveal documentation of a physician's order for staff to place the patient in a hold on 01/12/18, nor did nursing staff note an assessment of the patient while in or after the SCM hold. Review of pictures taken of Patient #1 on 01/13/18 at 9:05 PM, revealed there were several red/pink scratch marks in both armpits and the surrounding skin had a darker red to pink discoloration. A photograph of the patient's neck also revealed a red scratch. Review of the Nursing Shift Assessment Note, dated 01/12/18 timed 6:51 AM, revealed nursing staff did not document any abnormalities with the patient's skin. A Nursing Shift Assessment Note, dated 01/12/18 at 4:18 PM, revealed the patient had no abnormal skin issues noted. A Nursing Shift Assessment Note, dated 01/13/18 at 6:18 AM and 3:29 PM, revealed nursing did not note Patient #1 had any scratches or bruising to the neck or armpits. Interview with Patient #1, on 02/28/18 at 3:20 PM, revealed Mental Health Worker (MHW) #1 grabbed him/her under the arms and around the neck and it hurt. The patient stated MHW #2 pulled him/her by the arm to get him out of a chair and the treatment provided by MHW #1 and #2 made him/her feel sad. The patient stated MHW #1 took him to his/her room, which made him upset and he/she went off. Review of Video Surveillance Footage, dated 01/12/18 and timed 7:58 PM, revealed Patient #1 seated in the dayroom with other patients and staff. Patients were not violently acting out or being physically aggressive requiring staff intervention. MHW #2 walked over to the seated Patient #1 and placed her hands on the patient's right hand and shoulder, and then pulled Patient #1 out of the chair by the right arm. The patient dropped to the floor attempting to get out of MHW #2's grasp. Further video review revealed MHW #2 bent over to pull the patient up off the floor by placing her hands under the patient's armpits. The hallway camera view revealed MHW #2 continued to attempt to pull Patient #1 up off the floor with difficulty while the patient wiggled around on the floor trying to prevent staff from picking him/her up. The hallway camera view revealed MHW #1 got up out of his chair and walked over to Patient #1 and bent over to assist MHW #2 with picking the patient up off the floor. MHW #1 pulled the patient up off the floor from behind by placing his hands in the armpits of the patient. Once Patient #1 was up off the floor, MHW #1 pulled up on the patient's armpits causing the patients elbows to be at ear level. While remaining behind the patient, MHW #1 kept his hands in Patient #1's armpits and quickly rushed the patient down the hall towards the patient's room. MHW #1 than released the patient from his grasp while he unlocked the patient's door. The hallway camera view revealed the patient entered his/her room once the door was open, then the door closed behind the patient, but did not shut completely. Immediately, MHW #1 entered the room, a few seconds passed and MHW #1 exited the patient's room. Patient #1's door closed again and again MHW #1 went back into the room. The camera view from inside Patient #1's room revealed the patient was seated on his/her bed and MHW #1 entered the room and bent down and got his/her face within inches of the patient's face. The video did not have audio; however, a conversation between the patient and MHW #1 was observed and the patient exhibited upset facial expressions and body language. MHW #1 then left the room and Patient #1 started tearing up his/her glasses. Interview with Registered Nurse (RN) #1, on 02/22/18 at 2:13 PM, revealed Patient #1's mother complained to staff on 01/13/18, regarding bruises and scratches she found in the patient's armpits and a scratch on the neck. RN #1 stated she assessed Patient #1's skin and there were scratches and bruising to both armpits and a scratch to the neck area. She stated she photographed the patient's neck and both armpits and reported the mother's concerns to the House Manager. According to RN #1, she did not receive a report from off going staff that the patient had been in a recent hold or sustained scratches or bruising. She stated she was not sure how the injuries happened. Interview with the House Manager, on 02/23/18 at 8:12 AM, revealed she received a report from Patient #1's mother regarding bruising to the patient's armpits. She stated she assessed the resident's underarms and witnessed the bruising and scratches. Interview with MHW #2, on 02/22/18 at 2:00 PM, revealed on 01/12/18 around 8:00 PM, Patient #1 became upset because he/she did not earn the special reward snack for good behavior that shift. She stated the patient was seated in the dayroom when he/she started screaming and disrupting the milieu; however, she stated the patient did not make any threats and was not a harm to self or others. She stated she was concerned the screaming would cause the other patient's in the dayroom to react so she requested the patient take a time-out and the patient refused. MHW #2 stated after the patient refused to take a time-out, she reached for the patient's arm to do a SCM technique called Extended Arm to get the patient out of the chair and to an area for a time-out. She stated she removed the patient from the chair by grabbing the patient by the right wrist and then the patient dropped to the floor and she made several attempts to pull the patient up off the floor but was unsuccessful. She stated MHW #1 came over and pulled the patient up off the floor for her and took the patient to his/her room for a time-out. Interview with MHW #1, on 02/23/18 at 10:55 AM, revealed on 01/12/18 at about 8:00 PM, after staff passed out snacks, Patient #1 yelled and disrupted the milieu so MHW #2 verbally prompted the patient to take a time-out and the patient refused to take a voluntary time-out, so MHW #2 performed a touch prompt and the patient went down to the floor. He stated he went to help get the patient off the floor because he thought the patient would listen to him more than MHW #2. MHW #1 stated if staff initiated a touch prompt and the patient did not comply with the requested time-out, staff would physically escort the patient to the time-out area. MHW #1 stated he alone got the patient up off the floor using a Hook and Carry technique, then transferred the patient to his/her room using an Extended Arm technique. However, review of the video footage of the incident revealed MHW #1 did not use the appropriate SCM techniques to get the patient up off the floor or to his/her room. In addition, the MHW did not identify the patient was not a danger to himself/herself or others to require the forced time-out or restraint. MHW #1 stated after the patient entered his/her room, he/she began to perform property destruction by slamming the door so he went back into the room, got down in the patient's face, and told the patient he/she would get another mark off on his/her flowsheet, making it harder to earn the snack reward. He stated he did not inform the nurse about the restraint holdings he used on Patient #1 because he thought the nurse witnessed them as he walked Patient #1 through the unit. MHW #1 stated the next day he was suspended and called in to speak to the Risk Coordinator (RC) who went over the video footage with him. He stated the RC told him he should have called a code for assistance and used the appropriate SCM holds when he dealt with Patient #1. Interview with RN #5, on 02/27/18 at 10:25 AM, revealed she worked on 01/12/18 and left before 8:00 PM. She stated Patient #1 had no skin issues she was aware of and the patient did not report any bruising or scratches to her prior to her leaving for the night. She stated the patient had not been in a hold during her shift that could have potentially caused the injuries reported. Interview with RN #2, on 02/23/18 at 11:15 AM, revealed MHW #1 or #2 did not report to him they laid their hands on Patient #1 in order to restrain, or that the patient had refused a time-out. He stated he saw MHW #1 escorting Patient #1 down the hall; however, he could not see any behavior from where he was in the hallway that he considered inappropriate. He stated staff was not to force patients to take a time-out, and if staff forced a time-out, it was considered a seclusion requiring a physician order. In addition, if a restraint was necessary, he had to obtain a physician's order and do the appropriate patient assessments. He stated he was not aware staff used a non-approved SCM hold on Patient #1 in order to do the necessary notifications and assessments. Interview with the Unit Manager (UM), on 02/22/18 at 9:30 AM, revealed she received a report that Patient #1's mother informed staff of bruises and scratches on armpits and neck. She stated she viewed the video footage of staff interaction with Patient #1 on 01/12/18, to determine what happened and noted MHW #2 prompted the patient out of the chair; however did not see the footage where the patient was on the floor and MHW #2 attempted to pick the patient up off the floor. Nor did she note MHW #1 picked the patient up off the floor. She stated she did view the footage where MHW #1 escorted the patient to his/her room and did not see anything that concerned her. However, the UM stated putting hands on patients should be the last resort for staff and staff should use the least restrictive intervention first. The UM stated physically forcing a patient to take a time-out was not hospital policy. She stated staff could have removed the other patients from the area if they thought Patient #1's behavior was escalating after he/she did not want to take a self-time-out. According to the UM, she did not conduct formal training of staff after the incident to re-educate staff on approved restraint use policy and procedures or the time-out process. Interview with the Safe Crisis Management Instructor, on 02/22/18 at 3:05 PM, revealed MHW #1 and #2 did not use approved SCM techniques when they interacted with Patient #1. He stated after reviewing the video footage, he re-educated MHW #1 on the approved techniques; however, he did not identify the need to re-educate MHW #2 after she pulled on the patient's arm to remove him/her from the seat. He stated both MHWs should have used an approved SCM technique to assist the patient up off the floor. Interview with the Director of Nursing (DON), on 03/09/18 at 3:15 PM, revealed the video footage was reviewed and it was determined MHW #1 used a non-traditional intervention with Patient #1 after the patient refused to take a time-out. She stated the facility retrained MHW #1 on SCM; however, did not identify the need to re-educate MHW #2 or nursing staff regarding time-outs, SCM, or restraint and seclusion procedures. Interview with the Chief Nursing Officer (CNO) and the Chief Executive Officer (CEO), on 03/09/18 at 4:15 PM, revealed their role was to provide oversight and direction. Each stated they were ultimately responsible for the care and services delivered by staff. The CNO stated he reviewed the video of the incident with Patient #1 and determined MHW #1 used a non-standard intervention with Patient #1 and the facility re-educated the MHW and allowed him to return to work. He stated the facility routinely provided monthly, quarterly, and yearly training on SCM techniques. However, after the incident concerning Patient #1, neither the CNO nor the CEO directed leaders to provide all staff with immediate re-education on use of time-outs, SCM, or restraint procedures. |
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| VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION | Tag No: A0168 | |
| Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to ensure seclusion and restraint (S&R) implementation was in accordance with the physician order for five (5) of ten (10) sampled patients. Review of Patient #1's clinical record revealed the facility did not obtain a physician order to place the patient in a restraint or seclusion on 01/12/18. In addition, nursing staff did not obtain orders directing staff on time limit restrictions or clinical justification related to S&R for Patients #4, #5, #8 and #9. The findings include: Review of the facility's Restraint and Seclusion Policy, dated March 2017, revealed the facility focused on protecting and preserving patient rights, dignity, and well-being during the use of restraints in accordance with a written modification to the patient's plan of care. The facility would promote the safe application and removal of restraint and seclusion by competent staff. A physical restraint was any manual method or mechanical device, material, or equipment that immobilized or reduced the ability of a patient to move his/her arms, legs, body, or head freely. This included any therapeutic Safe Crisis Management (SCM) physical holding. Restraints would not be used as punishment, for convenience of staff, or response to behaviors or circumstances that do not constitute a danger of injury to the patient or others. Restraint use was limited to situations where there was appropriate clinical justification based on a comprehensive assessment of the patient. Restraint for management of violent or self-destructive behavior would only be used in emergency situations to ensure the patient's safety and less restrictive interventions were ineffective. Per the policy, an emergency situation was defined as a situation where the patient's behavior was violent or aggressive and where behavior presented an immediate and serious danger to the safety of the patient, others, and staff. In some situations, the need for a restraint intervention might occur so quickly that an order could not be obtained prior to the application of the S&R. In these situations, the nurse could initiate S&R and obtain an order from the physician during the emergency application or immediately after the application. For Violent/Self Destructive Behavior S&R, time should be limited to four (4) hours for adults, children ages nine (9) to seventeen (17) for two (2) hours, and children younger than nine (9) years old for one (1) hour. Each episode of S&R should be documented in the medical record and include the order from the Licensed Independent Professional. The order must contain the type of restraint, specific time limits, the patient's condition or symptoms that warranted the use of S&R, the alternatives or least restrictive interventions attempted first, and the patient's response to the interventions and rational for continued use. Review of the facility's Safe Crisis Management (SCM) Instructor Manual, dated 2015, revealed the use of emergency safety physical intervention referred to the application of force that restricted a patient's mobility/movement. Types of Emergency Safety Interventions staff would implement included time-outs, seclusion, and restraints. A time-out was a teaching strategy where patients could learn to calm themselves while not participating in current routine or activity. Seclusion was the placement of a patient against their will in a designated room. A physical, mechanical, and or chemical restraint could also be implemented. A physical restraint was the application of physical force by one or more individuals that reduced or restricted the ability of the patient to move his/her arms, legs, or head freely. The level of force that could be used in these circumstances was governed by the principle of the least restrictive alternative, which meant the intervention must be employed in the least amount necessary to ensure a safe outcome. The use of excessive force was a violation of social policy and legal principals. 1. Record review revealed the facility admitted Patient #1 on 12/21/17, with diagnoses of Mild Mental Retardation, Disruptive Behavior Disorder, and History of Sexual Abuse. The patient was thirteen (13) years old with a recent history of suicidal threats and auditory hallucinations. Observation of Patient #1, on 02/28/18 at 3:20 PM, revealed the patient was in the Kid Zone participating in a group activity. Continued review of the clinical record revealed nursing staff noted, on 01/13/18 at 9:22 PM, Patient #1 reported to his/her mother that staff scratched him/her under both arms during a SCM hold on 01/12/18. However, the record did not contain a physician order directing staff to place Patient #1 in a SCM hold on 01/12/18. Further review of the clinical record revealed the facility had taken photographs of Patient #1's reported scratches on 01/13/18 at 9:05 PM. The photographs revealed several red/pink scratch marks in both armpit areas and the surrounding skin in the armpits had a darker red to pink discoloration. A photograph of the patient's neck revealed a red scratch. Interview with Patient #1, on 02/28/18 at 3:20 PM, revealed Mental Health Worker (MHW) #1 grabbed him/her under the arms and around the neck and it hurt. The patient stated MHW #2 pulled him/her by the arm to get him out of a chair. The patient stated MHW #1 took him to his/her room, which made him upset and he/she went off. Interview with MHW #2, on 02/22/18 at 2:00 PM, revealed on 01/12/18 around 8:00 PM, Patient #1 became upset because he/she did not earn the special reward snack for good behavior that shift. She stated the patient was seated in the dayroom when he/she started screaming and disrupting the milieu. MHW #2 stated the patient did not make any threats and was not harm to self or others, but she was concerned the screaming could cause the other patient's in the dayroom to react, so she requested the patient take a time-out and the patient refused. MHW #2 stated after the patient refused to take a time-out, she reached for the patient's arm and tried to use an Extended Arm SCM hold in order to get the patient out of the chair and to an area for a time-out. Once she got the patient out of the chair, the patient dropped to the floor and she stated she attempted several times to pull the patient up out of the floor using the SCM Hook and Carry hold, but was unsuccessful. Therefore, MHW #1 came over, pulled the patient up off the floor and took the patient to his /her room for a time-out. MHW #2 stated if staff placed a patient in a hold, a physician's order must be obtained. She stated she did not inform Registered Nurse (RN) #2 she had used holding techniques to remove the patient from the chair or to get the patient up off the floor. Interview with MHW #1, on 02/23/18 at 10:55 AM, revealed on 01/12/18 at about 8:00 PM, staff distributed snacks and Patient #1 started yelling and disrupting the milieu, so MHW #2 verbally prompted the patient to take a time-out and the patient refused. He observed MHW #2 performed a touch prompt with Patient #1 and the patient went down to the floor. MHW #1 stated if staff initiated a touch prompt and the patient did not comply with the requested time-out, staff would physically escort patient to the time-out area, which was part of the unit behavior protocol. MHW #1 stated whenever a MHW placed a patient in a S&R hold using SCM techniques, they had to notify the nurse in order for the nurse to obtain a physician's order. MHW #1 stated after the patient dropped to the floor, he alone got the patient up off the floor using a Hook and Carry SCM technique and transferred the patient to his/her room for the time-out procedure. MHW #1 stated he did not informed RN #2 about the SCM holds he used to get the patient up off the floor and to his/her room for a time-out. Interview with RN #2, on 02/23/18 at 11:15 AM, revealed he must obtain a physician order when the decision was made to implement S&R. He stated MHW #1 and #2 did not inform him they had used SCM holding techniques to remove Patient #1 from the chair or to get the patient up off the floor. He stated staff could not use holds without an order. Interview with the 3 South Unit Manager (UM), on 02/22/18 at 9:30 AM, revealed the use of S&R required a physician order. She stated after Patient #1's mother reported the patient's injuries to nursing staff, nurse leadership and the Risk Management team investigated the incident. However, the team did not identify the need for corrective action regarding the failure to obtain a physician order for the holds the MHWs used with Patient #1. Interview with the Director of Nursing (DON), on 03/09/18 at 3:15 PM, revealed the facility investigated the reported injuries to Patient #1's armpits and neck. However, it was not determined staff had used SCM holds without a physician's order. She stated the facility believed the MHWs used non-traditional holds that did not require a physician order. Interview with the Chief Nursing Officer (CNO) and the Chief Executive Officer (CEO), on 03/09/18 at 4:15 PM, revealed a physical restraint was any manual method that immobilized or reduced the ability of a patient to move his/her arms, legs, body, or head freely, which included any therapeutic use of SCM physical holdings. However, it was not determined the facility failed to obtain a physician order for the reported use of SCM holds by MHW #1 and #2 with Patient #1. The CEO and CNO stated they believed MHW #1 and #2 used non-traditional holds that did not require nursing staff to obtain a physician order. 2. Review of the clinical record for Patient #4 revealed the facility admitted the twelve (12) year old patient on 02/14/18, with a diagnosis of Disruptive Behavior Disorder. Review of a S&R Event Note, dated 02/14/18, revealed the grandmother brought the Patient #4 to the facility for admission and the patient ran once they arrived. Staff followed and placed the patient in several S&R holds and then transitioned to five (5) point restraints. Review of Patient #4's S&R Order, dated 02/14/18, revealed nursing did not document a clinical justification for placing the patient in S&R. Interview with RN #3, on 02/28/18 at 9:40 AM, revealed Patient #4 bolted once his/her grandmother brought him/her to the facility for admission, requiring the staff to chase him/her and place in S&R. Review of Patient #4's S&R Order with RN #3 revealed he did not obtain or document the clinical justification for the use of S&R per facility policy. He stated the policy required nursing staff to obtain/document justification. 3. Review of Patient #5's clinical record revealed the facility admitted the nineteen (19) year old patient on 02/18/18, with the diagnosis of Anxiety Disorder. Observation of Patient #5, on 02/22/18 at 1:35 PM, revealed the patient was in the dayroom on 2 Lourdes with two (2) staff present. Review of a S&R Event Note, dated 02/19/18, revealed nursing staff documented during safety rounds, staff observed Patient #5 superficially scratching his/her wrist with a ring and the patient had minor bleeding and used his/her blood to draw on the wall. Staff asked the patient to walk to the quiet room and to hand over the ring. Staff placed the patient in a SCM hold to remove the ring and then released the patient from the restraint. Review of Patient #5's S&R Order, dated 02/19/18, revealed staff placed the patient in a SCM hold at 10:40 PM, due to the patient superficially scratching and causing the patient to bleed. However, the S&R Order did not contain a time restriction limit in relation to the patient's age. Telephone interview with RN #9, on 03/09/18 at 12:38, revealed during safety rounds, staff noted Patient #5 was using a ring to scratch his/her wrist. RN #9 stated staff requested the ring from the patient and the patient refused to hand it over so staff placed the patient in a restraint and the ring was peeled out of his/her hand. RN #9 stated she did not realize she had not obtained or documented the time limited restriction for Patient #5. She stated the time limit directed staff in how long they could S&R the patient according to the patient's age. She stated if staff did not obtain that information, a patient could be left in S&R longer than their age allowed. Interview with the 2 Lourdes Unit Manager (UM), on 02/28/18 at 11:15 AM, revealed she audited her units use of S&R by reviewing medical records. She stated she had not identified any issues that required her attention or staff re-education. The UM stated the S&R policy directed staff to obtain an order with a time limited restriction according the patient's age. She stated if nursing staff did not obtain the information, staff might leave a patient in S&R longer than required by age. 4. Review of Patient #8's clinical record revealed the facility admitted the seven (7) year old patient on 02/05/18, with the diagnoses of Anxiety Disorder and Disruptive Behavior Disorder. The patient also had a history of abuse and neglect. Observation of Patient #8, on 02/22/18 at 1:40 PM, revealed the patient was sitting on the floor taking a break. Review of a S&R Event Note, dated 02/20/18, revealed Patient #8 was directed to take a time-out, refused, and when staff touch prompted, the patient kicked staff and staff placed the patient in a multi-person Carry Cradle restraint hold and a Sitting Cradle hold. Review of Patient #8's S&R order, dated 02/20/18 and timed 11:45 AM, revealed nursing staff obtained an order to use Cradle Assist and Cradle Carry SCM holds. However, failed to obtain a time limit restriction or document the clinical justification for the use of S&R. Interview with RN #6, on 02/27/18 at 9:27 AM, revealed nursing staff must obtain a physician's order for the use of SCM holds and he must have over looked obtaining the time limited restrictions and failed to document the clinical justification for S&R use with Patient #8. Interview with the 2 North Unit Manager, on 03/09/18 at 2:34 PM, revealed she had not identified any issues with Patient #8's S&R orders that required her attention. She stated she was responsible for the nursing care delivered on her unit. 5. Review of Patient #9's clinical record revealed the facility admitted the thirteen (13) year old patient on 02/12/18, with diagnoses of Disruptive Mood Dysregulation Disorder, Autism Spectrum Disorder, and Receptive Expressive Language Disorder. Observation of Patient #9 in the 3 East Classroom, on 02/22/18 at 1:05 PM, revealed the patient was non-verbal and staff had the patient by the hand. Review of a S&R Event Note, dated 02/17/18 and timed 12:50 PM, revealed Patient #9 threw a cup of water and then attempted to hit and bite staff. Staff placed the patient in a multi person Seated Upper Torso hold for safety. The patient struggled during the hold but eventually calmed down and staff released the patient from the hold. Review of a S&R Event Note, dated 02/17/18 and timed 3:05 PM, revealed Patient #9 got very angry when he/she did not earn his/her reward snack and started screaming and slapping staff. Staff placed the patient in a SCM restraint hold and escorted in a SCM hold to the time-out room in order to take a time-out. Review of a S&R Event Note, dated 02/17/18 and timed 3:57 PM, revealed Patient #9 started screaming, jumping on tables, and charging at staff. Staff placed the patient in a SCM hold and patient continued to fight with staff and staff secluded the patient after the patient refused to comply. Nursing staff noted at 4:00 PM, the patient was screaming in the seclusion room and kicked the door repeatedly, at 4:04 PM the patient started taking his/her clothes off. Nursing staff noted at 4:09 PM, the patient continued to scream and pace in the seclusion room. At 4:20 PM, nursing staff noted the patient appeared calm and seclusion discontinued. Review of Patient #9's S&R Orders, dated 02/17/18, revealed staff placed the patient in S&R at 12:50 PM, 3:05 PM, and 3:57 PM. Nursing staff did not document a clinical justification for the S&R for the 12:50 PM, and the 3:57 PM event did not contain a time limited restriction in relation to the patient's age. Interview with RN #4, on 02/28/18 at 1:53 PM, revealed when Patient #9's S&R Physician Order was reviewed with RN #4, she acknowledged she did not obtain nor document the clinical justification for the use of S&R on 02/17/18 at 3:01 PM. RN #4 revealed at 3:57 PM, she obtained another S&R Order after Patient #9 started screaming, jumping on tables, and charging and scratching staff. Review of the physician order with RN #4 revealed she acknowledged the order did not contain physician directed time restrictions for the application of S&R. She stated time restrictions were required due to the developmental age of the patient. According to RN #4, she overlooked the time restriction limit for Patient #9, which would have been two (2) hours. RN #4 stated if the S&R order did not contain all the required elements, staff would have to release the patient. Continued interview, on 03/09/18 at 3:15 PM, with the DON revealed the facility routinely audited S&R orders. However, she had not identified an issue with nursing staff documentation of S&R orders or with nursing staff obtaining time limited restrictions according to the patient's age. She stated a time limit restriction was part of the S&R order and it directed staff in the length of time a patient could be kept in S&R. The DON stated she had not provided nursing staff re-education or direction to ensure S&R orders were complete with a time limited restriction per the facility policy, nor had she directed nurse leaders to re-educate nursing staff on the S&R policy time limited restriction requirements. She stated she was responsible for the care and services delivered by the nursing staff. Continued interview with the CNO and the CEO, on 03/09/18 at 4:15 PM, revealed they were ultimately responsible for the care and services delivered by staff. They both stated their role was to provide oversight and direction to staff. However, they had not identified S&R orders did not contain all required policy elements. They both stated the facility performed routine audits of S&R use; however, data provided to them did not indicate issues requiring their attention or direction. They did not direct leaders to re-educate staff regarding the S&R policy requirements for obtaining an order. |
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| VIOLATION: RN SUPERVISION OF NURSING CARE | Tag No: A0395 | |
| Based on observation, interview, record review, video review, and job description reviews, it was determined the facility failed to ensure nursing staff evaluated and supervised the nursing care of patients in relation to seclusion, restraint, and time-out procedures for one (1) of ten (10) sampled patients, Patient #1. The findings include: Review of the facility's Job Description for the Director of Nursing (DON), revised 03/11/16, revealed the DON had the responsibility to direct, plan, coordinate, monitor, and evaluate nursing and patient outcomes. The DON would provide leadership and effective personnel management by maintaining and evaluating employee performance along with providing opportunities for staff development. In addition, the DON would supervise employees to ensure quality work. Review of the facility's Registered Nurse (RN) Job Description, revised November 2017, revealed the RN would provide nursing care in accordance to the nursing process, including assessment, diagnosis, planning, implementing, and evaluating. The RN would implement appropriate nursing care interventions in accordance with physician orders and established nursing policies and procedures. Record review revealed the facility admitted Patient #1 on 12/21/17, with diagnoses of Mild Mental Retardation, Disruptive Behavior Disorder and history of Sexual Abuse. The clinical record revealed the patient was thirteen (13) years old with a recent history of suicidal threats and auditory hallucinations. Review of Patient #1's Treatment Plan, dated 02/20/18, revealed the goal was for the patient to participate in 100 % of his/her treatment programing. The interventions instructed staff to reinforce coping skills such as having the patient talk with staff when angry and take a self time-out. Observation of Patient #1, on 02/28/18 at 3:20 PM, revealed the patient was in the Kid Zone participating in a group activity. Interview, on 02/22/18 at 2:00 PM, with Mental Health Worker (MHW) #2 revealed on 01/12/18 around 8:00 PM, Patient #1 became upset because he/she did not earn the special reward snack for good behavior that shift. She stated the patient was seated in the dayroom when he/she started screaming and disrupting the milieu, but was not making any threats and was not a harm to self or others. She stated she was concerned the screaming could cause the other patient's in the dayroom to react so she requested the patient take a time-out and the patient refused. MHW #2 stated after the patient refused to take a time-out, she reached for the patient's arm to do a Safe Crisis Management (SCM) technique called Extended Arm to get the patient out of the chair and to an area for a time-out. Once she got the patient out of the chair the patient dropped to the floor and she made several attempts to pull the patient up off the floor but was unsuccessful. She stated MHW #1 came over and pulled the patient up off the floor and took the patient to his/her room for a time-out. Continued review of the clinical record revealed nursing staff noted on 01/13/18 at 9:22 PM, Patient #1 reported to his/her mother staff scratched him/her under both arms during a SCM hold on 01/12/18. However, the clinical record did not reveal documentation of a physician's order that allowed or justified staff to place the patient in a hold on 01/12/18, nor did nursing staff note an assessment of the patient while in or after the SCM hold. Review of pictures taken of Patient #1 on 01/13/18 at 9:05 PM, revealed there were several red/pink scratch marks in both armpits and the surrounding skin had a darker red to pink discoloration. A photograph of the patient's neck revealed a red scratch. Review of a Nursing Shift Assessment Note, dated 01/12/18 at 6:51 AM, revealed nursing staff did not document any abnormalities with Patient #1's skin. A Nursing Shift Assessment Note, dated 01/12/18 at 4:18 PM, revealed the patient had no abnormal skin issues noted. A Nursing Shift Assessment Note, dated 01/13/18 at 6:18 AM and 3:29 PM, revealed nursing staff did not note Patient #1 had any scratches or bruising to the neck or armpits. In addition, nursing staff did not document staff interventions in regards to actions taken on 01/12/18, when the patient became upset over not earning his/her reward snack. Interview with Patient #1, on 02/28/18 at 3:20 PM, revealed MHW #1 grabbed him/her under the arms and around the neck and it hurt. The patient stated MHW #2 pulled him/her by the arm to get him out of a chair. The patient stated the treatment provided by MHW #1 and #2 made him/her feel sad. The patient stated MHW #1 took him to his/her room, which made him upset and he/she went off. Review of the facility's Video Surveillance Footage, dated 01/12/18 and timed 7:58 PM, revealed Patient #1 seated in the dayroom with other patients and staff. The patients were not violently acting out or being physically aggressive requiring staff intervention. Further observation revealed MHW #2 walked over to the seated Patient #1 and placed her hands on the patient's right hand and shoulder and pulled Patient #1 out of the chair by the right arm. The patient then dropped to the floor, attempting to get out of MHW #2's grasp. MHW #2 bent over to pull the patient up off the floor by placing her hands under the patient's armpits. Observation from the hallway camera angle revealed MHW #2 continued to attempt to pull Patient #1 up off the floor with difficulty as the patient wiggled around on the floor trying to prevent the staff from picking him/her up. The hallway camera angle revealed MHW #1 got up out of his chair and walked over to Patient #1 and bent over to assist MHW #2 with picking the patient up off the floor. MHW #1 pulled the patient up off the floor from behind by placing his hands in the armpits of the patient. Once Patient #1 was up off the floor, MHW #1 pulled up on the patient's armpits causing the patient's elbows to be at ear level. While remaining behind the patient, MHW #1 kept his hands in Patient #1's armpits and quickly rushed the patient down the hall towards the patient's room. MHW #1 than released the patient from his grasp while he unlocked the patient's door and the patient entered his/her room once the door was open, then the door closed behind the patient, but did not shut completely. Immediately, MHW #1 entered the room, a few seconds passed, and MHW #1 exited the patient's room. Patient #1's door closed again and MHW #1 went back into the room. The camera view from inside Patient #1's room revealed the patient was seated on his/her bed and MHW #1 entered the room and bent down and got his/her face within inches of the patient's face. The video did not have audio; however, a conversation between the patient and MHW #1 was observed and the patient exhibited upset facial expressions and body language. MHW #1 then left the room and Patient #1 started tearing up his/her glasses. Interview with RN #1, on 02/22/18 at 2:13 PM, revealed Patient #1's mother complained to staff on 01/13/18, regarding bruising and scratches she found in the patient's armpits and a scratch on the neck. RN #1 stated she assessed Patient #1's skin and saw scratches and bruising to both armpits and a scratch to the neck area. She stated she photographed the patient's neck and both armpits and reported the mother's concerns to the House Manager. She stated off going staff did not report to her that the patient had been in a recent hold or had sustained scratches or bruising during a hold and was not sure how the injuries happened. RN #1 stated if a patient was in a hold, staff was to obtain a physician order, and perform and document assessments in order to evaluate patient care to update the patient's care plan. Interview with the House Manager, on 02/23/18 at 8:12 AM, revealed she received a report from Patient #1's mother regarding bruising to the patient's armpits. She stated she assessed the resident's underarms and witnessed the bruising and scratches. Interview with MHW #1, on 02/23/18 at 10:55 AM, revealed on 01/12/18 at about 8:00 PM, staff gave out snacks and rewards for good behavior. He stated Patient #1 received his/he snack but got upset because he/she did not receive the reward snack and the patient was yelling and disrupting the milieu so MHW #2 verbally prompted the patient to take a time-out. He stated the patient refused to take a voluntary time out, so MHW #2 performed a touch prompt and the patient then went down to the floor. MHW #1 stated if staff initiated a touch prompt and the patient did not comply with the requested time-out, staff would physically escort patient to the time-out area. MHW #1 stated he alone pulled the patient up off the floor using a Hook and Carry technique then transferred the patient to his/her room for the time-out procedure. After the patient entered his/her room, he/she slammed the door so MHW #1 went back into the room, got down in the patient's face, and told the patient he/she would get another mark off on his/her flowsheet, making it harder to earn the snack reward. He stated he did not inform the nurse about the forced time-out or restraint holdings he used on Patient #1 because he thought the nurse witnessed them as he walked Patient #1 through the unit. MHW #1 stated the next day he was called in to speak to the Risk Coordinator (RC) who went over the video footage with him and the RC told him he should have called a code for assistance and used the appropriate SCM holds when he dealt with Patient #1. Interview with RN #2, on 02/23/18 at 11:15 AM, revealed neither MHW #1 nor #2 reported to him they laid their hands Patient #1 in order to restrain, or that the patient refused a time-out. He stated he did see MHW #1 escort Patient #1 down the hall; however, he could not see any behavior from where he was in the hallway that he considered inappropriate. RN #2 stated staff was not to force patients to take a time-out and if staff forced a timeout, it was considered a seclusion requiring a physician order. He stated if he had known staff had forced Patient #1 to take a time-out, he would have intervened, assessed the patient, re-educated staff, and made notifications to supervisors. Interview with the Unit Manager (UM), on 02/22/18 at 9:30 AM, revealed she received a report that Patient #1's mother informed staff of bruises and scratches on the armpits and neck. She stated she viewed the video footage of staff interaction with Patient #1 on 01/12/18, to determine what happened and noted MHW #2 had prompted the patient out of the chair and did not see anything concerning with the interaction. She stated she viewed the footage of MHW #1 escorting the patient to his/her room and did not see anything on the video that concerned her. However, the UM stated putting hands on patients should be the last resort and staff should use the least restrictive intervention first. The UM stated physically forcing a patient to take a time-out was not facility policy. She stated nursing staff was responsible for supervising patient care and nursing staff should have assessed Patient #1 after the incident and documented their assessment. According to the UM, she had not provided the unit nursing staff any formal training after the incident in order to re-educate staff on the importance of supervision and evaluating patient care. Interview with the DON, on 03/09/18 at 3:15 PM, revealed the video footage was reviewed and it was determined MHW #1 used a non-traditional intervention with Patient #1 after the patient refused to take a time-out. She stated the facility retrained MHW #1 on SCM; however, did not identify the need to re-educate MHW #2, or nursing staff regarding assessments or supervising patient care. Interview with the Chief Nursing Officer (CNO) and the Chief Executive Officer (CEO), on 03/09/18 at 4:15 PM, revealed their role was to provide oversight and direction. Each stated they were ultimately responsible for the care and services delivered by staff. The CNO stated he reviewed the video of the incident with Patient #1 and determined MHW #1 used a non-standard intervention with Patient #1. He stated the facility re-educated the MHW and allowed him to return to work. However, after the incident concerning Patient #1, neither the CNO nor the CEO directed leaders to provide nursing staff with immediate re-education on the evaluation and supervision of care in relation to time-out or seclusion and restraint procedures. |
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