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.

CONNECTICUT VALLEY HOSP SILVER ST MIDDLETOWN, CT 06457 July 12, 2017
VIOLATION: PATIENT RIGHTS Tag No: A0115
The Condition of Patient Rights was not met as evidenced by:

1. The hospital failed to protect and promote each patient's rights and/or failed to ensure that patients received care in a safe setting as evidenced by:

a. The hospital failed to ensure that patients were free from all forms of abuse, neglect or harassment. The abuse included willful infliction of injury, unreasonable confinement, intimidation, or punishment. The abuse included physical abuse, mental abuse/anguish, sexual abuse, and/or exploitation;

b. The hospital staff failed to report to administration suspected or actual abuse, neglect, or exploitation is occurring or has occurred;

c. The hospital failed to report abuse, neglect, or exploitation to the appropriate to state agencies;

d. The hospital staff violated their work rules and/or neglected their duties when they failed to maintain 2:1 constant observations;

e. The hospital staff neglected their duties when staff used cellphones in a patient care area while performing constant observations;

f. The hospital failed to follow their own policies regarding abuse, neglect, and exploitation.

g. The hospital did not implement their abuse policy when staff made a threat about a patient;

h. The hospital failed to protect patients from abuse during investigation of allegations of abuse, neglect or harassment;

i. The hospital failed to ensure that incidents of abuse, neglect, or harassment were reported and analyzed, and the appropriate corrective, remedial or disciplinary action occurred;

j. The hospital failed to obtain informed consent, failed to obtain a physician's order, and document the use of video monitoring as an intervention on the treatment plan for continuous in room monitoring;

k. The hospital staff performing constant observations failed to carry a panic button in accordance with facility practice;

l. The hospital failed to implement a restraint policy with least restrictive interventions;

m. The hospital failed to ensure that patients were free from physical and mechanical restraints and/or restraints were not imposed as a means of coercion, discipline, convenience, or retlaiation by staff;

n. The hospital staff failed to ensure that staff consistently monitored the video surveillance cameras in all views;

o. The hospital failed to ensure there was adequate staffing to provide activities and groups;

p. The hospital failed to ensure that the environment was safe regarding maintenance and integrity of ceiling tiles throughout the facility;





Please reference A130, A131, A144, A145, A154, and A165

2. Based on review of facility documentation and policy for the Whiting Maximum Forensic Division, the hospital failed to ensure that patient rights were protected and/or promoted. The finding includes:

Review of the active inpatient census sheet dated 4/11/17 identified that the census of the Whiting Building was 92. The patients were not allowed to leave the building without police escort and can only leave for appointments or a medical hospital evaluation. Although the hospital had a policy on patient privileges which established standards and procedures for the granting and withholding of privileges at CVH and allowing for greater freedom and movement and access to programs and services in and about the hospital, on its grounds, and in the community consistent with due consideration of potential therapeutic and benefit and assessed level of risk, this policy and privilege level did not apply to the Whiting Maximum Security Service.
VIOLATION: PATIENT RIGHTS: PARTICIPATION IN CARE PLANNING Tag No: A0130
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



1. Based on a review of clinical records and a review of hospital documentation, the hospital failed to ensure that all patients in Whiting have the right to participate in admission and discharge planning. The finding includes:

Review of the active inpatient census sheet dated 4/11/17 identified that the census of the Whiting Maximum Building was 92. Thirty-five (35) of the patients' legal status included Psychiatric Safety Review Board (PSRB) Commitment. According to Connecticut General Statutes (CGS) Section 17a-582(e)(1), in part, when any person charged with an offense is found not guilty by reason of mental disease or defect pursuant to section 53a-13, the court shall order such acquittee committed to the custody of the Commissioner of Mental Health and Addiction Services who shall cause such acquittee to be confined, pending an order of the court pursuant to subsection (e) of this section, in any of the state hospitals for psychiatric disabilities or to the custody of the Commissioner of Developmental Services, for an examination to determine his mental condition. (e) At the hearing, the court shall make a finding as to the mental condition of the acquittee and, considering that its primary concern is the protection of society, make one of the following orders:

(1) If the court finds that the acquittee is a person who should be confined or conditionally released, the court shall order the acquittee committed to the jurisdiction of the board and either confined in a hospital for psychiatric disabilities or placed with the Commissioner of Developmental Services, for custody, care and treatment pending a hearing before the board pursuant to section 17a-583; provided (A) the court shall fix a maximum term of commitment, not to exceed the maximum sentence that could have been imposed if the acquittee had been convicted of the offense, and (B) if there is reason to believe that the acquittee is a person who should be conditionally released, the court shall include in the order a recommendation to the board that the acquittee be considered for conditional release pursuant to subdivision (2) of section 17a-584; or (2) If the court finds that the acquittee is a person who should be discharged , the court shall order the acquittee discharged from custody.

Although the Integrated Treatment Plans for 15 clinical records reviewed identified that discharge planning was reviewed during the planning meetings, the hospital relied on the PSRB for a final decision. The PSRB, at the time of commitment, who takes jurisdiction over the acquittee and decides which hospital an acquittee is to be confined and when and under what circumstances an acquittee can be released into the community. The other Whiting Maximum patients' status included competency restoration, probate commitment, 45/60 day evaluation, and voluntary admission.


2. Based on clinical record review, review of hospital policies, and interviews for 4 of 15 patients (Patient #82, #WH6-15, #85, and #84), the hospital failed to ensure that patient specific Engagement Activities were documented in the clinical record. The findings include:

a. Patient #82 was admitted on [DATE] for competency restoration with diagnoses of [DIAGNOSES REDACTED]. Review of Patient #82's Engagement progress notes dated 3/15/17 and 3/16/17 identified comments on the patient's participation each shift. However, the Engagement progress notes failed to identify what engagement activities were specific to Patient #82. Interview with the VP of Patient Care Services on 4/17/17 at 11:45 AM and the Director of Regulatory Compliance on 4/17/17 at 1:00 PM identified that the Engagement activity progress note should be completed to address the patient's specific engagement activities.

b. Patient #WH6-15 had diagnoses of [DIAGNOSES REDACTED]#85 would be praised for appropriate responses to engagement. However, the treatment plan failed to identify what Patient #85's specific engagements were.

c. Patient #85 was admitted with a diagnosis of [DIAGNOSES REDACTED]#85's Engagement progress notes dated 4/11/17, 4/12/17, 4/13/17, 4/14/17, 4/15/17 and 4/16/17 identified comments on the patient's participation each shift. However, the Engagement progress notes failed to identify what engagement activities were specific to Patient #85.

d. Patient #84's diagnoses included [DIAGNOSES REDACTED]. The treatment plan failed to identify that an engagement objective was added to the treatment plan. The Engagement Progress Notes dated 3/28/17 to 4/9/17 failed to identify the specific engagement activities.

Interview with the VP of Patient Care Services on 4/17/17 at 11:45 AM and the Director of Regulatory Compliance on 4/17/17 at 1:00 PM identified that the Engagement activity progress note should be completed to address the patient's specific engagement activities. A hospital memo dated 12/3/12 identified that treatment teams will identify individuals who require an engagement objective added to their integrated treatment plan. The MHA/FTS observations shall be documented on CVH-674 form, Mental Health Assistant/Forensic Treatment Specialist Engagement Progress Note.


3. Based on clinical record review, review of hospital policies, and interviews for 1 of 15 patients (Patient #82), the hospital failed to ensure that the clinical record identified justification for a body search and failed to ensure that the search was documented in the clinical record. The findings include:

Patient #82 was admitted on [DATE] for competency restoration with diagnoses of [DIAGNOSES REDACTED]. Interview with the VP of Patient Care Services on 4/17/17 at 11:45 AM identified that Patient #82 had a body search conducted by police on 2/20/17 due to a missing toothbrush, which was considered contraband. The VP of Patient Care Services identified that the body search should have been documented in the progress notes.


4. Based on review of the clinical record review and review of facility policy for 2 of 15 clinical records (Patient #84, Patient #86), the hospital failed to ensure that the treatment plan was conducted timely and/or was filed in the chart. The findings include:

a. Patient # 84 was transferred from unit 4 to unit 6 on 3/22/16. An integrated treatment plan was completed on 3/1/17 and the next integrated treatment plan was not completed until 4/17/17 (47 days later). According to the Integrated Treatment Planning Process Policy, the treatment plan review should be done every 30 days and within 7 days of transfer to another unit, then per rules based on length of stay.


b. Review of Patient #86's clinical records failed to identify an integrated treatment plan for March 2017. Subsequent to surveyor inquiry on 4/13/17, the staff obtained the 3/3/17 and 4/13/17 treatment plans for the chart. Interview with the Accreditation Manager at that time identified that the treatment plan had not been filed and could not explain why the integrated treatment plan had not been filed in the record.


5. Based on review of the clinical record and interview for Patient #18, the hospital failed to ensure that social work completed monthly notes. The finding incldues:

a. Patient #81's diagnoses included [DIAGNOSES REDACTED]. The clinical record identified that Social Worker #1 was Patient #81's social worker. According to hospital documentation, the patient was removed from Social Worker #1's caseload on 4/28/17. Interview with the Supervising Social Worker, Social Worker #1's supervisor, on 5/2/17 identified that he was covering Social Worker #1's caseload and/or groups (while Social Worker #1s Clinical Manager is on vacation) while Social Worker #1 has been reassigned to another area. Further interview identified that that social work notes are written at least monthly and sometimes more often, if needed. Review of the clinical record lacked documentation of a social worker note on Patient #81 due approximately 4/27/17, one month after the last note.
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



Based on observations, review of the clinical record an interview for 2 of 15 records reviewed (Patient #81, #40) for patient rights, the hospital failed to obtain informed consent for in room video monitoring and/or a physician's order for video monitoring and/or document the use of video monitoring as an intervention on the treatment plan for continuous in room video monitoring. The findings include:


1. Patient #81's diagnoses included [DIAGNOSES REDACTED]. Review of the clinical record failed to identify that the patient's conservator had given informed consent to have a camera in the patient's room and be continuously monitored. The Integrated treatment Plan also failed to reflect the use of continuous video monitoring as an intervention. The clinical record lacked a physician order or treatment plan intervention to include continuous video monitoring. Interview with MD #6 on 4/11/17 at 12:10pm identified that the patient was moved into his/her present room on 3/22/17 or 3/23/17 from another unit and the camera was already in the room and part of the unit so it was left on. Further interview identified that the patient's conservator was called on 4/10/17 and a message was left. Review of the Electronic Monitoring/Surveillance System policy identified that the use of electronic surveillance in designated patient bedrooms is based on a physician's order for the purpose of increased patient monitoring.

2. Patient #40 was admitted on [DATE] with diagnoses that included [DIAGNOSES REDACTED]. Interview with Chief Executive Officer (CEO) and Acting Division Director on 4/10/17 at 9:30 AM identified that Patient #40 had a camera in his/her room with a continuous video feed to the secure nursing/FTS area on the unit as well as to the hospital police (security). Review of the clinical record failed to identify that the patient's conservator had given informed consent to have a camera in the patient's room and be continuously monitored. The Integrated treatment Plan also failed to reflect the use of continuous video monitoring as an intervention. The clinical record lacked a physician order or treatment plan intervention to include continuous video monitoring. Interview with MD #6 on 4/11/17 at 10:00 AM identified that the use of the camera pre-dated his/her arrival at the hospital in 2015, however, over the years he/she was aware of both patient and staff injuries and incidents which may have resulted in the use of the camera for further monitoring and protection.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



1. Based on review of facility documentation and interview, the hospital failed to ensure that when there was an increase in abuse and neglect allegations and an increase in incidents, recommendations and/or actions were identified. The findings include:

Review of the Quality, Risk and Safety Committee meeting minutes dated 3/2/17 identified that allegations of abuse and neglect and the number of incidents had increased over the last quarter. Interview with the Director of Compliance and Performance Improvement on 4/12/17 at 1:45pm acknowledged that reporting of allegations and incidents had increased however, there were no recommendations identified and could not explain any facility's action to address the data.

Review of the Patient Safety Event and Data Incident policy identified that the hospital will track and trend data to evaluate the effectiveness of the Incident Management System and to identify and manage individual and systemic patterns and trends. For incidents that involve alleged abuse, neglect and exploitation, trends shall be tracked in at least the following categories, type of incident, staff involved and staff present, patients directly and indirectly involved, location of incident, date and time of incident(s), cause of incident, and outcome of the investigation. The Quality, Risk and Safety Committee is responsible for analyzing data and making recommendations for corrective action.



2. Based on observation, review of the clinical record and interview for 2 of 15 patients at risk for behaviors (Patient #81, #86), the hospital failed to ensure that staff performing constant observation carried a panic alarm (portable call alarm to alert staff) and/or failed to ensure staff was awake during their constant observation duty to ensure that care was provided in a safe setting and/or the level of observation orders were not consistent with facility policy. The finding includes:

a. Patient #81's diagnoses included [DIAGNOSES REDACTED]. Observation during tour on 4/24/17 at 9:10pm with DNS #2 identified FTS # 61 performing constant observation (staff to stay in the patient's line of sight at all times) of Patient #81 while sitting in the doorway. FTS #61 failed to carry a panic button while performing the constant observation. Interview with FTS #61 identified that he just relieved staff and didn't get a panic button. Interview with DNS #2 identified that it was facility policy/practice for staff to carry a panic button while assigned as a constant observer. Subsequent to surveyor inquiry, a panic button was immediately provided to FTS #61. The Special Observation policy failed to reflect that staff conducting special observation required a panic alarm.

b. Patient #86's diagnoses included [DIAGNOSES REDACTED]
i. Observation during tour of Unit 2 on 4/10/17 at approximately 11:45am with the Chief of Patient Care Services identified Patient #86 on constant observation (staff to stay in the patient's line of sight at all times) and monitored by FTS #21. The physician orders dated 3/7/17 to 4/12/17 directed constant observation or C.O. The Special Observation policy only defines continuous monitoring and does not describe constant observation. Review of the integrated treatment plan dated 3/27/17 failed to identify that the patient required constant/continous observation. The Special Observation Policy identified that whenever a level of observation of continuous observation or greater is initially ordered, a focused treatment plan review is completed by the team on the next business day.


ii. Observation of the patient with the Chief Operating Officer (COO) on 4/13/17 at 6:17am identified FTS #20 was assigned to perform constant observation of the patient (Patient #86). The patient was sleeping, FTS #20 was seated in the doorway leaned back in his chair with his eyes closed. As the surveyor and COO approached the FTS, his eyes opened. Interview with FTS #20 at that time denied having [DIAGNOSES REDACTED].

iii. Observation and interview with FTS #21 on 4/10/17 failed to identify that the FTS was carrying a panic button in accordance with facility practice. Further interview identified that the FTS would wave his/her arms if he needed to call the nurse or other staff for assistance since the unit had video monitoring of the hallways. Further observations identified that the nursing desk contained video monitors viewing the common areas of the unit (dining room, day room, and hallways). During tour, the video monitor in the nursing station was not being monitored by any staff. Interview with the Chief of Patient Care Services on 4/10/17 identified that all staff conducting constant monitoring should carry a panic button. Subsequent to this observation, a panic button was provided to FTS #21. Further interview with the Chief of Patient Care Services identified that staff are usually in the nursing station but the other FTS had been conducting safety and census checks on the unit. The Special Observation policy failed to reflect that staff conducting special observation required a panic alarm.


iv. Observation during tour on 4/25/17 at 8:45pm with DNS #2 identified 2 cups of liquid on the windowsill in Patient #86's bedroom. The patient was not in his/her room. Interview with DNS #2 at that time identified that patients are not allowed to have drinks in their room. Subsequent to surveyor inquiry, the drinks were removed from the patient's room.



3. Based on observations during tour and interview for three of five units (Unit 1, 2, and 6), the hospital failed to ensure that staff consistently monitored the video surveillance cameras and/or failed to ensure that all staff watched all of the available camera views at each nursing unit and/or failed to ensure that staff were adequately trained and/or failed to provide adequate staffing to conduct all scheduled activities. The findings include:

a. Based on observations during tour of the Whiting units on 4/10/16 between 12pm and 2pm, there was no staff in the nursing station monitoring the video monitors on units 1, 2, and 6. The cameras monitored patients and staff in the common areas and in one patient's room on units four and six. Additionally, the video monitors had the capability to view all nine camera views or select the number of views. Observations of the units identified that not all units consistently viewed all nine camera views. Unit staff were observed in the medication room, monitoring patients in the dining room or conducting safety checks. Interview with Chief of Patient Care Services at that time identified that staff should be in the nursing unit watching the cameras. Review of the facility Electronic Monitoring/Surveillance System identified that the electronic monitoring/surveillance system can greatly improve the security of the staff and patient. In order to be effective, the system needs to be properly maintained and monitored on a regular basis so that safety threats can be accurately assessed.
Subsequent to inquiry on 4/10/17, all Whiting Maximum staff were instructed to maintain all nine camera views, an in room camera view if there is one on the unit, and post a staff member in the nursing unit at all times to monitor staff and patient interactions.

b. Interview with RN #22 on 4/13/17 and review of the actual staffing from 4/10/17 to 4/13/17 identified that although a FTS staff is now assigned in the nursing unit to view the video cameras to monitor staff and patient interactions, the staffing was not increased to ensure that services and interventions were maintained. Interview with RN #21 on 4/13/17 identified that all of the units have been short staffed and 3 patients requiring constant observations added to the workload, therefore patients were not able to go into the courtyard the previous shift due to inadequate staffing, only one staff instead of two staff monitored dining, and a group meeting was not conducted due to inadequate staffing. Interview with RN #22 on 4/13/17 identified that she was concerned with the inadequate staffing and is concerned if staff are able to get to a patient on time to keep them safe. Further interview identified that all of the aforementioned concerns had been forwarded to management and it was reported that nothing had been done or changed to address the issues.

Interview with the Chief Operating Officer on 4/10/17 identified that although unit staff were monitoring the surveillance videos for patient and staff interactions, the campus police department also viewed the video from their office. Observation and interview with Police Officers (PO) #1 and #2 in the presence of the Chief of Patient Care Services on 4/11/17 identified that they can view the video monitors of the patient units in their "middle room" of the police booth, however, staff do not routinely watch these monitors and they are not staffed on the overnight shift to leave their station from the "main room".

c. Observation during tour of Unit 6 on 4/25/17 at approximately 6:45am identified FTS #40 assigned to watch the video monitors within the nursing unit. Interview with FTS #40 identified that she had been out of a leave since January 2017 and the night shift was her first shift back to work. FTS #40 further identified that she had was told by RN # 35 to watch the monitor and patient interactions and that RN #35 would check in with her periodically since FTS #40 was not familiar with the patients. FTS#40 further identified that she was not informed that she was to observe for staff/patient interactions but told to "watch the monitors". Review of FTS #40's education transcript identified that training on camera assignment responsibilities and camera monitoring checklist and documentation was not completed until 4/27/17, two days later.


4. Based on observations during tour and interview of the Whiting Maximum Building, the hospital failed to maintain a safe environment free of accident hazards. The findings include:

a. Observation during tour of Whiting unit 4 on 4/13/17 at approximately 6am identified that in two areas on the ceiling there were ceiling tiles observed to be sagging and not sealed which allows access to the ceiling above. One of the tiles had a corner missing and a piece of metal was exposed. Interview with RN #20 on 4/13/17 identified that workers were in the building on 4/12/17 running wires for a video monitoring system and probably disrupted the ceiling tiles. Further interview identified that a call was place for repair but there is not a maintenance worker scheduled on the night shift and that the repairs would have to wait until 7am. There were 21 patients on this unit and five patients were identified with suicidal ideation and/or self-harm behaviors.

Additionally, RN #20 noted that at times when there are issues with overflowing water or an overflowing toilet, repairs have to wait until 7am until a maintenance worker arrives unless the issue is considered an emergency.

b. Additional observations on 4/15/17 throughout Whiting Units 1, 2, 3, 4, and 6 identified sagging ceiling tiles, multiple ceiling tiles with cracks or large chips of tile missing. Interview with the Director of Facilities on 4/15/17 identified that the ceiling tiles are almost fifty years old and they do not make these tiles, therefore the chips need to be filled with caulk or the tiles need to be nailed to prevent sagging and to prevent patient access to the ceiling above.


5. Based on observations and interview for 2 of 7 seclusion/restraint rooms, the hospital failed to ensure that the rooms were free from dirt, debris, and maintained for safety. The finding includes:

a. Observations during tour of the Whiting units on 4/10/17 between 12:30 and 2pm identified dust and debris on the floors of the restraint/seclusion rooms on units 2 and 4. In addition, the seclusion room on Unit 2 had screws protruding from the radiator cover which posed a safety hazard. Interview with Chief of Patient Care Services on 4/10/17 identified that housekeeping staff has a schedule to clean the rooms and they are cleaned on a regular basis and could not explain why protruding screws were exposed on the radiator cover and have been that way for a while.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**




1. Based on interviews, review of policies and procedures, review of recorded video feed, and review of hospital documentation (video surveillance log) of Patient #40's room camera activity from 2/27/17 to 3/22/17, observation and documentation identified acts of abuse including physical abuse, mental abuse, sexual abuse, neglect, and exploitation and/or it was identified that staff failed to report suspected or actual abuse, neglect, or exploitation is occurring or had occurred regarding Patient #40 and/or failed to report allegations of abuse, neglect, exploitation to appropriate state agency(ies) and/or staff violated work rules by using their cellphones in a patient care area and/or staff neglected their duties while performing constant observation and/or for Patients #40, 90, and WH4-1, the hospital failed to follow their own policies regarding abuse, neglect and exploitation. The findings include:


a. Patient #40 was admitted on [DATE] with diagnoses that included schizoaffective disorder, autism spectrum disorder, osteoporosis, seizure disorder, recurrent aspiration pneumonia, psychogenic polydipsia, and a history of multiple fractures. Patient #40 had a legally appointed Conservator of Person (COP).

i. A Treatment Plan Review Dated 3/22/17 dated for February 2017 through March 2017 identified that Patient #40 continued to demonstrate problems with explosive affects, physical aggression, sexualized behaviors, impulsivity, and poor self-care. He/she had required intensive staff support to maintain safety and to ensure his/her ADLs are appropriately maintained. He/she required a physical intervention on 3/1/17 after becoming assaultive to staff. Objectives include that the Patient will use or attempt to use his/her personal preferences to better manage his/her frustrations and remain free of aggression to self and others as evidenced by a gradual reduction of acts of aggression and restraints. Additionally, Patient # 40 will participate in reality-based discussions regarding discharge planning for a minimum of five minutes, twice a week, over the next 3 months with staff.

ii. Physician Orders dated 3/2/17 through 3/22/17 directed that Patient #40 have constant observation (CO) with two (gender specific) staff members for protection of self and others, water intoxication, activities of daily living (ADL), and targeting staff of the opposite sex (verbal and physical assaults).

iii. In addition to CO, Patient #40 was monitored via continuous electronic video surveillance with a direct feed of the video image to the nursing station (no audio). There was also continuous video monitoring of the hallway outside of Patient #40's bedroom and throughout the unit (unit 6) for the same time period. Interview with MD #6 on 04/11/17 at 10:00 AM identified that Patient #40's video monitoring process was in place prior to MD #6 assuming care of Patient #40. In addition, review of the clinic record lacked current physician order, written consent by the COP, or intervention on the integrated treatment plan for the video monitoring.

iv. Interview with the hospital CEO on 4/10/17 at 9:31 AM identified that Patient #40's video monitoring was saved on file for the time period of 2/27/17 through 3/22/17. The CEO identified that multiple video images of staff interactions with Patient #40 were egregious with willful disregard of the hospital's abuse policies. Staff were observed taunting Patient #40, throwing food at the patient, and pouring water on his/her head. Staff held his/her arms (restraint), put an incontinent brief on his/her head, and put their feet on his/her bed, repeatedly. As of 4/10/17, the hospital had initiated an investigation, placed multiple staff members on administrative leave, re-educated staff on abuse and patient exploitation, contacted authorities, and were in the process of reviewing all existing video monitoring of Patient #40. The internal, hospital investigation was ongoing.

v. Review of hospital documentation of an incident dated 3/21/17 identified that on 3/21/17 (time unknown), the Chief of Patient Care Services was notified by an unknown person of alleged staff abuse towards Patient #40, and that video monitoring would provide evidence of the abuse. Abusive acts towards Patient #40 included putting hand sanitizer in his/her lotion and shampoo bottles, salt in his/her coffee and hot sauce in food. Patient #40 was kicked and bullied.

vi. Interview with the Director of Human Resources (HR) on 4/13/17 at 8:30 AM and on 4/18/17 at 2:00 PM identified that staff were reviewing all of the video monitoring of Patient #40's room and the hallway between 2/27/17 and 3/22/17. Incidents of abuse, mistreatment, neglect and other concerns related to patient care were being logged.

vii. Review of a Work Rule Violation Report dated and signed by the Chief of Patient Care Services on 03/21/17 at 4:00 PM identified that there was an alleged physical abuse of a client (Patient #40) including Work Rule Violation #19 (Physical violence, verbal abuse, inappropriate or indecent conduct and behavior that endangers the safety and welfare of persons or property is prohibited) as well as State Regulations #4, #8, #11, and #13. Persons that were notified (on 3/21/17) included the Acting Division Director and Master Sergeant #1. A description of the incident included that he/she had received a complaint that Patient #40 had been chronically abused on unit 6. The Chief of Patient Care Services was told that the patient had been given hand sanitizer rather than lotion to use for lubricant when engaging in sexualized behavior, given salt in his/her coffee, hot sauce in his/her food and hand sanitizer rather than shampoo. The patient was bullied and kicked.

viii. Specific dates were not given, however, the Chief of Patient Care Services was referred to review tapes for the day shift on 3/12/17 and 3/21/17 (the same day). The tape of 3/12/17 identified RN #24 and FTS #23 were not in direct line of view of Patient #40 when performing CO. FTS #23 placed a sheet over Patient #40''s face. FTS #25 was standing behind the door using a cell phone. RN #24 and RN #26 were having a conversation with FTS #25 while he/she was using a cell phone and did not redirect the FTS to put the contraband away. FTS #25 placed a drink towards his/her lips as if sipping from it or spitting in it and then gave it to Patient #40. FTS #25 placed his/her feet on the Patient's bed. The tape of 3/21/17 identified that FTS #23 and FTS #25 grabbed Patient #40 by the hands, held him/her on the bed while RN #24 forced a diaper on over his/her pants against his/her will. Several times, FTS #25 picked up a cookie from the floor and threw it at the Patient or on his/her bed. FTS #25 paced around Patient #40's bed pointing a diaper at him/her and, on two occasions, FTS #25 touched the patient on the leg with the diaper, clearly upsetting him/her as the Patient started pulling his/her legs away, trying to cover him/herself with blankets. FTS #25 went behind the Patient and placed the diaper on his/her head. RN #24 and FTS #23 sat in front of the Patient's room and observed FTS #25's behavior. RN #28 looked into the Patient's room and walk away. Following the documentation of the observation of tapes, the Chief of Patient Care Services identified the persons involved as RN #24, RN #28, and FTSs #23, #24, and #25.

ix. A Nursing Staff Assignment/Supervisor's Report for 3/21/17 identified that RN #24, RN #28, and FTSs #23, #24, and #25 were working from 6:45 AM through 3:15 PM. An Incident Report included in the packet was dated and signed 3/22/17 at 11:00 AM and identified Alleged Patient Abuse that included physical, psychological, neglect, and violation of patient rights. The staff and Patient involved were documented.

x. The Chief of Patient Care Services documented that he/she had seen staff abuse Patient #40 and other staff fail to report witnessing abuse. On 3/22/16 at 12:25 PM Assistant Division Director documented that a Work Rule Violation Report had been generated on four employees indicated on the first page of the report. Other areas of the form were left blank with a notation that the investigation was pending. Addendum B (Investigation Section) identified the incident dates of 3/12/17 and 3/21/17 and referred to previous documentation. Unit Acuity and Staff Issues section identified that staff attitude and/behavior escalated the situation and staff failed to utilize correct CSS techniques. Actions taken to protect victim included that the Patient was being moved to another unit today (3/22/17) and 3 staff were placed on administrative leave. Furthermore, other staff may be moved dependent upon administrative review.

xi. A Unit Director/Supervisor Check List for hospital Investigations of Abuse, Neglect, and Exploitation of Patients identified the following: Condition of patient assessed (blank); Appropriate medical care provided to patient (checked as not applicable(N/A), Alleged perpetrator removed from contact with patient (completed with three staff placed on administrative leave), Work Rule Violation Form completed (3/21/17, 4:00 PM), Incident Report competed and submitted to Division Directors office with Work Rule Violation by end of the shift (completed), Department of Division Director notified (completed), Public Safety notified (completed), Director of Recovery and Consumer Affairs notified, Statements taken from staff on unit prior to end of shift (no, per Labor Relations with reference to documentation dated 4/19/17). Documentation by Supervisor of Labor Relations dated 4/19/17 identified that due to possible tampering of evidence (video), witness statements were not collected per Labor Relations. A facsimile transmittal was forwarded from the hospital to Labor Relations on 3/22/17 regarding the incident on 3/12/2017.

xii. Review of the video surveillance tape on 4/13/17 identified that the incident on 3/21/17 (restraint, taunting and brief on head) began at approximately 11:37 AM and ended at approximately 11:42 AM. Review of Nursing Staff Assignment dated 3/21/17 for the 6:45 AM through 3:15 PM shift identified that RN #24, RN #28 FTS for the 6:45 AM through 3:15 PM shift FTS #25, and FTS #23 were working. Staffing for 03/22/17 for the 6:45 AM through 3:15 PM shift identified that RN #24 worked from 6:45 AM through 7:45 AM, FTS #25 worked from 6:45 AM through 8:15 AM and was assigned to care for Patient #40, and FTS #23 worked from 6:45 AM through 8:15 AM before being placed on administrative leave. RN #28 was not placed on administrative leave.

xiii. Review of the clinical record identified that Patient #40 exhibited episodes of yelling and screaming on the evening and night shifts of 3/21/17 and early morning of 3/22/17 and was transferred from unit 6 to unit 4 on 03/22/17 at approximately 2:15 PM for administrative reasons. Documentation lacked evidence of education and/or support provided related to the transfer.

xiv. A Monthly note dated 03/22/17 by MD #6 at 1:35 PM identified that the case was discussed with the accepting psychiatrist and, at the time of the transfer, Patient #40 was noted to be calm, at baseline, and in no physical distress. The note lacked documentation regarding the circumstances of the transfer, recommendations for additional support, and/or assessment for potential of physical harm related to alleged abuse, mistreatment, and/or neglect.

xv. The Chief of Patient Care Services and The Acting Division Director were aware of the allegation prior to 4:00 PM on 03/21/17 however, they failed to ensure that Patient #40 was free of contact with the identified staff until they were placed on administrative leave on 03/22/17.

xvi. Interview with the Chief of Patient Care Services and the Acting Division Director on 04/12/17
at 3:30 PM identified that the Acting Division Director arrived at the hospital at 6:30 AM on 03/22/17 with the intent of placing the identified staff on administrative leave prior to their shift commencing at 6:45 AM, however, he/she was unable to secure representation from Labor Relations timely, and the staff worked until the administrative leave documents could be presented to each staff member privately.

Interview with the Director of Client's Rights on 05/02/17 at 9:00 AM identified that, although he/she was not a clinician, he/she was asked to interact with Patient #40 to evaluate how he/she was acclimating to the change in units following the alleged incidents. In preparation for the interactions, the Director of Client's Rights identified that he/she reviewed portions of the video surveillance tape. During the interactions, he/she encouraged Patient #40 to discuss who, what, where, when, and/or how the alleged incidents of abuse, mistreatment, and/or neglect occurred, however, the patient did not respond to efforts to explore the alleged issues on unit 6. Review of the Director of Client's Rights documentation of patient interviews identified that the first interview was conducted on 3/27/17 (6 days after the incidents were discovered) and continued on 3/30/17, 4/04/17, 4/07/17, 4/11/17, and 4/12/17.

Segments of video monitoring of Patient #40 in his/her bedroom and of the hallway were reviewed with the Director of Human Resources on 4/13/17. With the assistance of the Director of Human Resources, names of staff members observed on the video were identified and the following was observed:



xvii. On 2/27/17 at 5:43 PM, identified that Patient #40 was observed on his/her bed with Forensic Treatment Specialist (FTS) #31 and FTS #35 sitting in chairs next to the bed. FTS #31 had his/her feet resting on top of Patient #40's bed while FTS #32 entered the room and sat on Patient #40's bed. FTS #32 was observed reaching out and repeatedly tapping or poking Patient #40 on the arm, chest and lower legs in a manner consistent with taunting. Patient #40 responded by tapping FTS #32 back. FTS #32 continued to tap Patient #40 repeatedly until Patient #40 got out of the opposite side of the bed and was no longer visible on the video. At 5:45 PM, Patient #40 returned to his/her bed and FTS #32 returned and again, sat on Patient #40's bed and began pushing Patient #40's body forcefully. Patient #40 then pushed FTS #32 back. At 5:48 PM, FTS #32 and FTS #35 left the room and FTS #31 remained in the room with his/her feet on the bed.

xviii. Review of a Positive Behavioral Support Plan and/or Special Observation sheet with documentation every 15 minutes identified that on 2/27/17 between 5:00 PM and 5:45 PM, Patient #40 was in the bedroom exhibiting repetitive ritual behaviors with no interventions identified. At 5:45 PM, FTS #24 documented that Patient #40 was threatening staff with a behavior of aggression against others.

xix. A nurses note dated 2/27/17 at 10:00 PM by RN #24 identified that Patient #40 exhibited no aggression towards self or others besides a 15 minute spitting episode, and the patient had soiled him/her self and refused a shower. The plan included to continue to monitor and provide a safe environment.

xx. In this time frame of 2/27/17, FTS #24, #31, #32 and FTS #35 were identified as present during some or all the abusive acts and did not appear to respond, or come to Patient #40's aid, and did not report the incidents of physical and psychological abuse to administration.


b. On 3/1/17 at 7:00 AM Patient #40 was in bed and appeared to be agitated and screaming. FTS #25 was observed bending over the bed in close proximity to Patient #40's face. FTS #25 raised his/her right hand and appeared to push Patient #40's shoulder/left jaw area. In response, Patient #40 raised his/her left arm in an apparent defensive position.

i. Review of a Positive Behavioral Support Plan and/or Special Observation sheet with documentation every 15 minutes (author unknown) identified that on 3/1/17 at 7:00 AM Patient #40 was awake and exhibiting repetitive ritualistic behaviors with no interventions identified.
Although Patient #40 was on CO with two staff, the incident of physical and psychological abuse was not reported.

ii. A Physician Order for restraints dated 03/01/17 at 10: 40 AM by MD #6 and RN #27 directed to place Patient #40 in Physical Restraint not to exceed 20 minutes, and mechanical restraint not to exceed 2 hours (4 point) due to imminent risk of assaultive aggression as evidenced by hitting, kicking, spitting. Physical and/or psychological risk considerations included, osteopenia and history of aspiration pneumonia. Discontinuation criteria included, calm, cooperative, and non-aggressive behavior.

Review of restraint documentation dated 03/01/17 at 11:00 AM by RN #24 identified that Patient #40 was punching at staff, swinging, lunging, chasing, and spitting. The Patient was offered and refused a quiet area (refused and stormed out) and staff offered to talk with the Patient and he/she screamed and attempted to strike at the staff member. A Secure Guide Escort and Third Person Assist was implemented at 10:40 AM followed by a Physical Hold at 10:45 AM. Four Point Restraints were applied at 10:45 AM and discontinued at 12:25 AM.

iii. Review of video surveillance of the restraint episode from 10:30 AM through 10:42 AM identified that Patient #40 was on the bed in his/her room. FTS #25 (involved in an incident of physical and psychological abuse of Patient #40 that AM) was visible behind the door. A lighted screen consistent with a cellular phone was visible. FTS #25 and Patient #40 exited the room and entered the hallway at 10:35 AM. At 10:36 AM, Patient #40 returned to his/her room followed by FTS #25 and FTS #36. FTS #36 exited the bedroom at 10:37 followed shortly by FTS #25 and Patient #40 who was moving rapidly with arms extended. Patient #40 attempted to strike FTS #37, and FTS #25 placed his/her hands on the Patient's upper arm and wrist in what appeared to be a Secure Guide Escort Hold. The Patient pulled away and five other staff approached. Within one minute the patient sat on the floor. Immediately, the patient attempted to lie down on the floor and was curled up on the floor with approximately 5 staff surrounding him/her. At 10:39 AM a restraint bed was wheeled into the hallway and the Patient was lifted onto the bed. Four point restraints were applied. The Patient did not appear to resist. At 10:41 AM the patient was wheeled into the restraint room and out of view.

iv. Review of the fifteen minute documentation of the Positive Behavioral Support Plan and/or Special Observations failed to validate the Behaviors of Concern documented prior to the initiation of restraints. The behaviors documented included repetitive ritualistic behaviors and, although the Patient required re-orientation away from ritualistic behaviors; aggressive, assaultive, or in-appropriate behaviors directed towards staff were not documented. Further review of restraint documentation identified that Patient #40 yelled, spit, and pulled at the restraints from 10:55 AM through 11:55 AM and then was lying down, quietly and asked to be released at 12:25 PM. Trazadone 100 mg and Valium 10 mg were ordered by MD #6 and administered by mouth at 11:30 AM. Patient #40 sustained inch abrasion at the back of his/her head during the restraint episode

v. Review of a list of things that made it more difficult for the patient when he was already upset included being touched, people staring at him/her, yelling, and the time of year including the anniversary of the crime he/she committed (02/26/1995)

The Patient had been subjected to physical and psychological abuse at 7:00 AM and the alleged perpetrator approached him/her later potentially causing the patient further mental anguish as evidenced by his/her aggressive response to the staff. A physical interaction involving touching by staff ensued resulting in four point restraint. Oral medications were not offered and/or administered until 11:30 AM, delaying the possible calming effect and prolonging the need for restraints. Documentation lacked evidence that the time of year in relation to the crime committed and/or other issues were considered prior to implementing or discontinuing physical and mechanical restraints. Review of the Seclusion/Restraint Patient Debriefing form dated 3/1/17 at 11:00 AM by RN #27 identified that Patient #40 refused to answer the 10 questions on the form, however, the form was signed and dated prior to the discontinuation of restraints at 12:25 PM, additionally, the Staff Debriefing form was completed at 11:15 AM prior to prior to the discontinuation of restraints at 12:25 PM.

vi. On 3/1/17 at 1:10 PM Patient #40 was in bed while FTS #24 and FTS #27 were providing CO in Patient #40's room when FTS #25 (refer to incident of 7:00 AM, the same day) entered the room with a plate of food and was observed eating the food with a spoon. Patient #40 reached out towards the plate of food and FTS #25 began to throw food from the spoon towards Patient #40's face four (4) times. The food landed on Patient #40's bed. Patient #40 was observed picking up and eating the thrown food. FTS #25 continued to eat food from the plate.

vii. Review of a Positive Behavioral Support Plan and/or Special Observation sheet with documentation every 15 minutes by FTS #25 identified that on 3/1/17 at 1:00 PM Patient #40 was eating with no observed behaviors of concern with interventions to offer food and fluids. At 1:15 PM FTS #25 documented that Patient #40 was eating with no concerning behaviors with interventions to offer food and fluids. At 1:30 PM FTS #25 identified that Patient #40 was yelling at staff with behaviors of concern identified as aggression against patients or staff. No interventions were identified.

viii. Interview with the CEO identified that the plate of food was intended for Patient #40 and FTS #25's behavior of throwing food at Patient #40 was an abusive act and should not have occurred.
On 3/1/17 at 7:10 PM, FTS #27 was observed displaying fighting type gestures towards Patient #40, which was observed by FTS #24.

ix. Review of a Positive Behavioral Support Plan and/or Special Observation sheet with documentation every 15 minutes by unknown staff identified that on 3/1/17 between 7:00 PM and 7:30 PM Patient #40 was in the bedroom resting, exhibiting repetitive ritual behaviors, and other psychotic behaviors with no interventions were identified.

x. On 3/1/17 at 11:08 PM, Patient #40 was in bed and FTS #2 and FTS #30 were observed sitting with their feet on Patient #40's bed. FTS #30 was observed using his/her feet to repeatedly push/kick Patient #40 until Patient #40 was pushed to the point where he/she fell out of the bed onto the floor. Patient #40 got his/herself off the floor, got back in bed, and FTS #30 was again observed to kick Patient #40 in his/her torso.

xi. Review of a Positive Behavioral Support Plan and/or Special Observation sheet with documentation every 15 minutes by unknown staff identified that on 3/1/17 at 11:00 PM Patient #40 was in the room resting exhibiting repetitive ritualistic behaviors and no interventions identified. Between 11:00 PM and 3/2/17 at 12:15 PM the observation sheet was incomplete. At 12:15 AM, FTS #24 documented that Patient #40 was hitting staff, showed aggression towards others, however, no interventions were identified.

xii. A nurses note dated 3/2/17 at 6:00 AM RN #25 identified that Patient #40 yelled and screamed at staff threatening to assault them and spit at staff, but, eventually calmed down until 6:00 AM. The plan included to continue to observe and provide a safe environment.

xiii. In this time frame of 3/1/17, FTS #2, FTS #25, FTS #27 and FTS #30 were identified as present during these abusive acts and did not to respond to, or come to Patient #40's aid and did not report the incidents of abuse to administration.

c. On 3/7/17 at 5:57 AM Patient #40 was observed in bed, FTS #27 and FTS #31 were in the patient's room. RN #25 was in the room and was observed to grab Patient #40, cover the patient's face with a bed sheet, and pulled Patient #40's arm and leg. Patient #40 rolled side to side and RN #25 was observed circling around the bed. Patient #40 appeared agitated and tried to protect him/herself by thrashing in the bed with a blanket and sheet. RN #25 pulled the sheet over Patient #40's head a second time while holding the patient down. Review of hallway video monitoring during this time frame identified that FTS #26 looked into Patient #40's room at the same time that RN #25 put a sheet over the patient's head.

i. RN #25 and FTS #31 left the room. RN #25 returned to the room with a cup of liquid while FTS #26 was sitting with his/her feet on Patient #40's bed. RN #25 was observed to pour liquid on Patient #40. Patient #40 grabbed the cup and the cup fell to the floor. RN #25 was observed taking Patient #40's sheet off the bed, using the sheet to wipe the liquid off the floor and leaving the room. RN #25 returned to the room with a mop and rolling mop bucket. RN #25 was observed mopping the wet floor and then placed the dirty, wet, mop head on Patient #40's head, moving the mop back and forth in a jabbing motion. RN #25 was observed moving the mop from the floor to Patient #25's head approximately 3 times.

ii. Review of a Positive Behavioral Support Plan and/or Special Observation sheet with documentation every 15 minutes by an unknown staff person on 3/7/17 from 6:00 AM through 6:15 AM identified that the patient was initially awake in bed with interventions of concern that included repetitive, ritualistic behaviors and other psychotic symptoms and, documentation by FTS #26 beginning at 6:30 AM through 7:00 AM that included behaviors of spitting, yelling, and kicking with behaviors of concern that included, ritualistic behaviors and other psychotic symptoms.

iii. The Integrated Progress Note dated 3/7/17 at 6:00 AM by RN #25 identified that Patient #40 was loud and yelling frequently at the staff performing CO without provocation. When awake, the patient would engage in repetitive behaviors including refusal of clothing. RN #25 identified that he/she would continue to monitor and provide a safe environment. An RN Shift Note dated 03/07/17 at 2:00 PM by RN #24 identified that Patient #40 was disrobing, fixated on paper-shredding rituals, engaged in sexualized behavior, and screamed at staff, but was not physically aggressive towards staff or other patients.

iv. In this time frame of 3/7/17, RN #25, FTS #26, and FTS #31 were identified as present during some or all the abusive acts and did not to respond to, or come to Patient #40's aid and did not report the incidents of abuse to administration.

d. Review of hospital Work Rule Violation Report dated 3/21/17 identified that, the Chief of Patient Care Services viewed video monitoring of care provided to Patient #40 on 3/12/17 (Day shift-no time indicated). It was identified that RN #24 and FTS #23 did not have a direct line of view of Patient #40 during the time they were assigned to provide CO. FTS #23 was observed placing a sheet over Patient #40's face while FTS #25 was behind the door using a cell phone. RN #24 and RN #26 were observed conversing with FTS #25 while using the cell phone and they failed to direct FTS #25 not to use the cell phone. FTS #25 was observed putting a drink to his/her lips in a sipping or spitting manner then gave the drink to Patient #40. FTS #25 was observed with his/her feet on Patient #40's bed.

i. Review of a Positive Behavioral Support Plan and/or Special Observation sheet with documentation every 15 minutes FTS #26, FTS #24 identified between 3:30 AM and 7:00 AM Patient #40 was identified as threatening staff, yelling, kicking, hitting, and spitting. No interventions were identified. At 9:15 AM, 9:30 AM, and 9:45 AM Patient #40 was in the bedroom identified as naked. Interventions included engagement. At 10:15 AM FTS #37 documented that Patient #40 had defecated in his/her clothing with a plan for engagement. At 10:30 AM Patient #40 was identified as sitting naked in his/her excrement. At 10:45 AM Patient #40 was showered. Between 1:00 PM and 1:30 PM Patient #40 was disrobing repeatedly. Interventions included engagement.

ii. A nursing note dated 3/12/17 at 12:45 PM documented by RN #29 identified that Patient #40 engaged in ritualistic behavior, had a labile mood, was incontinent and was showered; ate well, and took medications as prescribed. The plan included to continue to monitor and provide a safe environment.

iii. During this time frame on 3/12/17, RN #24, RN #26, FTS #23 and FTS #25 were identified as being present during these abusive acts, did not respond to, or come to Patient #40's aid, and did not report the incidents of abuse to administration. Adequate monitoring was not provided to identify abuse and/or provide a safe environment.

e. On 3/19/17 at 8:23 PM Patient #40 was in bed sleeping and FTS #30 was seated with his/her feet on Patient #40's bed. FTS #30 was holding a drink bottle, stood up, and began to shake Patient #40. FTS #30 then poured the liquid contents of the drink bottle on Patient #40. FTS #30 was observed pouring liquid on Patient #40 approximately 10 times, removing Patient #40's blanket during this time period. Patient #40 get out of bed and FTS #30 was observed to poke the patient who returned back to bed. FTS #30 again poured liquid on Patient #40's head, the patient rolled to the other side of the bed while FTS #30 continued to pour fluid on the patient. FTS #30 was observed going in and out of Patient #40's room several times and was observed with a gallon type container of liquid. FTS #30 took Patient #40's blanket and sheet away. Patient #30 sat up in bed with his/her hands covering his/her head while FTS #30 raised the liquid container over the patient's head and poured the liquid on the patient, intermittently, for a period of approximately 3 minutes. Patient #40 got out of bed and FTS #30 left the room. FTS #3 was observed to be present, behind the bedroom door during this incident. Patient #40 was standing in the corner of the room when FTS #30 returned with a clean shirt and bed linen. FTS #30 put dry sheets on the bed and the patient got back in the bed. FTS #30 motioned with his/her hands as if pouring liquid over the patient. FTS #30 was observed to leave the room again and return with additional bed linen. FTS #30 is observed, again, pouring liquid on Patient #40, who then got out of bed. FTS #30 and Patient #40 both walked behind the bed and Patient #40 appeared to be falling backwards several times. FTS #30 continued to pour water on Patient #40 when he/she was out of the bed.

i. At 8:59 PM, FTS #2 and FTS #38 were observed in Patient #40's room in the same time frame when FTS #30 was repeatedly pouring water on Patient #40.

ii. Review of a Positive Behavioral Support Plan and/or Special Observation sheet with documentation every 15 minutes by FTS #30 identified at 8:15 PM Patient #40 was asleep. At 8:30 and 8:45 PM Patient #30 is yelling and/or mumbling in bed, however, no behaviors of concern were documented and no interventions were identified 9:00 AM Patient was yelling and pacing, however no behaviors of concern were documented and no interventions were identified.

iii. A nursing note dated 3/19/17 at 10:00 PM identified that Patient #40 had a good night overall with episodic yelling and racial slurs. The Patient engaged in ritualistic behaviors, napped, ate well, refused 8:00 PM medications but experienced no aggression or assaults. Will continue to monitor and provide a safe environment.

iv. In this time frame of 3/19/17, FTS #2 and FTS #3 were identified as present during this abusive act and did not to respond to, or come to Patient #40's aid and did not report the incident of abuse to administration. Adequate monitoring was not provided to identify abuse and/or provide a safe environment.

f. On 3/21/17 at 11:36 AM Patient #40 was in bed when RN #24 was observed attempting to put a pull-up incontinent brief on the patient over his/her pants while FTS #23 and FTS #25 held Patient #40's arms. Patient #40 resisted and struggled as the RN appeared to force the brief over the patient's legs. A fourth person, RN #28 entered the room during this incident. Patient #40 removed the brief, threw it to the floor and RN #24 picked it up and placed it on the door knob in the patient's r
VIOLATION: USE OF RESTRAINT OR SECLUSION Tag No: A0154
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



1. Based on observation, review of clinical records, hospital policy and procedure and interviews for 2 of 2 patients reviewed for restraint utilization, Patients #40 and #80 the hospital failed to ensure that physical and/or mechanical restraints were not imposed as a means of coercion, discipline, convenience, or retaliation by staff. The findings include:

a. Patient #40 was admitted on [DATE] with diagnoses that included schizoaffective disorder, autism spectrum disorder, osteoporosis, seizure disorder, recurrent aspiration pneumonia, psychogenic polydipsia, and a history of multiple fractures.

i. A Treatment Plan Review (TPR) dated 3/22/17 for February 2017 through March 2017 identified that Patient #40 continued to demonstrate problems with explosive affect, physical aggression, sexualized behaviors, impulsivity, and poor self-care. He/she had required intensive staff support to maintain safety and to ensure his/her ADLs were appropriately maintained. He/she required a physical intervention on 3/1/17 after becoming assaultive to staff. Objectives included that the Patient would use or attempt to use his/her personal preferences to better manage his/her frustrations and remain free of aggression to self and others as evidenced by a gradual reduction of acts of aggression and restraints.

ii. Physician Orders dated 3/2/17 through 3/22/17 directed that Patient #40 have constant observation (CO) with two (gender specific) staff members for protection of self and others, water intoxication, activities of daily living (ADL), and targeting staff of the opposite sex (verbal and physical assaults).

iii. A Physician Order for restraints dated 03/01/17 at 10: 40 AM by MD #6 and RN #27 directed to place Patient #40 in Physical Restraint not to exceed 20 minutes, and mechanical restraint not to exceed 2 hours (4 point) due to imminent risk of assaultive aggression as evidenced by hitting, kicking, spitting. Physical and/or psychological risk considerations included, osteopenia and history of aspiration pneumonia. Discontinuation criteria included, calm, cooperative, and non-aggressive behavior.

iv. Review of restraint documentation dated 03/01/17 at 11:00 AM by RN #24 identified that Patient #40 was punching at staff, swinging, lunging, chasing, and spitting. The Patient was offered and refused a quiet area (refused and stormed out). Staff offered to talk with the Patient and he/she screamed and attempted to strike at the staff member. A Secure Guide Escort and Third Person Assist was implemented at 10:40 AM followed by a Physical Hold at 10:45 AM. Four Point Restraints were applied at 10:45 AM and discontinued at 12:25 AM.

v. Review of video surveillance of the restraint episode from 10:30 AM through 10:42 AM identified that Patient #40 was on the bed in his/her room. FTS #25 (involved in an incident of physical and psychological abuse of Patient #40 that AM) was visible behind the door. A lighted screen consistent with a cellular phone was visible. FTS #25 and Patient #40 exited the room and entered the hallway at 10:35 AM. At 10:36 AM, Patient #40 returned to his/her room followed by FTS #25 and FTS #36. FTS #36 exited the bedroom at 10:37 followed shortly by FTS #25 and Patient #40 who was moving rapidly with arms extended. Patient #40 attempted to strike FTS #37, and FTS #25 placed his/her hands on the Patient's upper arm and wrist in what appeared to be a Secure Guide Escort Hold. The Patient pulled away and five other staff approached. Within one minute the patient sat on the floor. Immediately, the patient attempted to lie down on the floor and was curled up on the floor with approximately 5 staff surrounding him/her. At 10:39 AM a restraint bed was wheeled into the hallway and the Patient was lifted onto the bed. Four point restraints were applied. The Patient did not appear to resist. At 10:41 AM the patient was wheeled into the restraint room and out of view.

vi. Review of the every fifteen minute documentation of the Positive Behavioral Support Plan and/or Special Observations failed to validate the Behaviors of Concern documented prior to the initiation of restraints. The behaviors documented included repetitive ritualistic behaviors and, although the Patient required re-orientation away from ritualistic behaviors; aggressive, assaultive, or in-appropriate behaviors directed towards staff were not documented. Further review of restraint documentation identified that Patient #40 yelled, spit, and pulled at the restraints from 10:55 AM through 11:55 AM and then was lying down, quietly and asked to be released at 12:25 PM. Trazadone 100 mg and Valium 10 mg were ordered by MD #6 and administered by mouth at 11:30 AM. Patient #40 sustained inch abrasion at the back of his/her head during the restraint episode.

vii. Review of a list of things that made it more difficult for the patient when he was already upset included being touched, people staring at him/her, yelling, and the time of year including the anniversary of the crime he/she committed (02/26/1995).

viii. The Patient had been subjected to physical and psychological abuse at 7:00 AM and the alleged perpetrator approached him/her later potentially causing the patient further mental anguish as evidenced by his/her aggressive response to the staff. A physical interaction involving touching by staff ensued resulting in four point restraint. Oral medications were not offered and/or administered until 11:30 AM, delaying the possible calming effect and prolonging the need for restraints. Documentation lacked evidence that the time of year in relation to the crime committed and/or other issues were considered prior to implementing or discontinuing physical and mechanical restraints.

ix. Review of the Seclusion/Restraint Patient Debriefing form dated 3/1/17 at 11:00 AM by RN #27 identified that Patient #40 refused to answer the 10 questions on the form, however, the form was signed and dated prior to the discontinuation of restraints at 12:25 PM, additionally, the Staff Debriefing form was completed at 11:15 AM prior to the discontinuation of restraints at 12:25 PM.


2. Review of an incident report on Patient #40 initially dated 4/17/17 identified that the date of the incident was crossed out and replaced with 3/19/17. The report, documented by the Assistant Division Director, identified alleged physical patient abuse towards Patient #40 with FTS #33 identified as the aggressor. Other staff involved included FTS #34, FTS #60, RN #34, and RN #26. PT #40 attempted to strike FTS #34 and was immediately grabbed from behind in a bear hug type of hold and taken down to his/her bed in a rough manner. FTS #40 went into the Patient's room held his/her legs. Other staff responded and entered the room. FTS #60, put his/her hand on the Patient's forehead while RN #26 and RN #34 entered the room.

i. According to the Assistant Division Director, Patient #40 was held briefly on the bed for less than one minute. No medications were administered. No restraints were ordered, and no paperwork was generated. Review of nursing documentation including the integrated progress notes dated 3/19/17 at 1:45 PM by RN #26 and Positive Behavioral Support Plan/Special Observation identified that the Patient was aggressive and yelling, but failed to identify that the Patient required a take-down and/or type of physical restraint.

ii. The physical restraint episode lacked physician notification, a physician order, and/or restraint documentation and/or an RN Assessment prior to or after the episode. Additionally, the one person take-down was not in accordance with Collaborative Safety Strategies (CSS) training. The time of the occurrence was unclear with the investigation dated 4/17/17.

iii. A hospital restraint policy identified that all patients have the right to be free from restraint, of any form, imposed as a means of coercion, discipline, convenience or retaliation by staff and directed that the RN assesses and documents the situation and obtains and documents physician's order. The physician describes the patient's specific behaviors which are observable and measurable necessitating immediate risk and the behavioral criteria necessary for release/discontinuation.


j. Patient #80 was admitted on [DATE] following a lengthy hospitalization at another acute care hospital. Diagnoses included paranoid schizophrenia, continuous. Review of an Annual Present Status/Treatment Plan Review (TPR) dated 8/5/16 by MD #6 identified that Patient #80 had a history of persistent mental illness, multiple long-term hospitalization s due to psychotic thinking and severe assaultive behaviors. The Patient had demonstrated a decrease in physical aggression and required one episode of physical restraints on 6/27/16. The Patient's insight was poor with limited judgement.

i. An Annual Nursing Re-assessment dated 8/13/16 identified personal preferences that included lying down with a cold face cloth, additional/extra medication, exercise, going for a walk, having a warm or cool drink, watching TV, talking with another patient, eating something, talking to staff, or listening to music. Things that made it more difficult when the patient was upset included being touched, not having input/choices, noise in general, bedroom door being opened, and yelling.

ii. An Integrated Treatment Plan (ITP) dated 02/14/17 identified objectives that included refraining from physical aggression including touching, hitting, and/or kicking or sexual inappropriateness for four consecutive months by utilizing his/her personal preferences of engaging in social and leisure activities, utilizing quiet time in room, practicing skills taught in groups, and taking prescribed medications.

iii. Review of a nursing progress note dated 3/3/2017 at 9:30 PM by identified that Patient #80 was maintained on Constant Observation for protection of others. At approximately 3:20 PM, and without warning or provocation, the patient hit a staff member. A code was called, the patient was placed in four point restraints and Thorazine 100mg and Benadryl 100 mg was administered by mouth for acute aggression per physician order at 3:40 PM. No injury was noted and the patient was in four point restraints for 1 hour and 55 minutes.

iv. Review of Restraint documentation identified that a takedown occurred at 3:20 PM, with a physical hold at 3:21 PM, and a secure guide escort at 3:23 PM. 4 Point restraints were applied at 3:24 PM and removed at 5:15 PM.

v. Review of the video surveillance tapes on 4/18/17 identified that on 3/3/17 at 3:18 PM, FTS #22 is identified standing in the hallway. FTS #46 and FTS #2 are observed sitting in the hallway. Patient #80 approached FTS #22 and punched him/her in the abdomen. FTS #22 held Patient #80's arm, pushing the patient against the wall as he/she slid the patient down the wall to the floor. One of the other FTS's stood up and eight other staff came on the scene. RN #20, MD #6, and a Police Officer were also present. The Patient was assisted to a standing position and escorted to the seclusion room utilizing a secure guide escort.

vi. FTS #22 failed to perform the take down and physical hold in accordance with hospital policies and procedures. Additionally, the Staff Debriefing Form identified that non-physical intervention techniques were not utilized due to the immediacy of patient's behavior that necessitated immediate physical response by staff and, furthermore, the technique was done correctly.

vii. Documentation failed to identify interventions attempted following the secure guide escort, take down, and physical hold that necessitated the utilization of four point restraint and/or why medications were not administered prior to the utilization of four point restraint.

viii. Interview with the Chief Executive Officer (CeO) on 04/10/17 at 10:00 AM identified that the hospital's review of the video surveillance of the restraint episode involving Patient #80 and FTS #22 identified that the single person take down was not in accordance with CSS training and represented an inappropriate use of restraint.

ix. Interview with multiple staff members on 05/02/17 at 2:13 PM identified that although all staff received Collaborative Safety Strategies (CSS) training upon hire and annually, the training did not include strategies on how to safely deal with an unanticipated direct assault by a patient when other staff is not readily available. At this time, staff identified that the CSS training is only available on-line and they did not have sufficient time to thoroughly complete the training. Additionally, hands on, supervised, training with practice sessions is lacking.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0165
Based on review of facility policy and interview, the hospital failed to implement a restraint policy with least restrictive interventions. The findings include:

Review of the restraint log dated dated 2/1/17 to 4/10/17 identified that restraint types included take down, physical hold, secure guide escort, and 4 point restraints. Interview with the Chief of Patient Care Services on 4/13/17 identified that the hospital does not use 2 point restraints. Review of the Restraint Use for the Management of Violent or Self Destructive Behavior policy identifies that the approved mechanical restraints approved for use at the hospital include in part, four-point restraints. Prior to the initiation of restraint, therapeutic interventions are employed considering patient-specific triggers as a means to help the patient regain control of his/her behavior, use of secure guide escort or a third person assist. The policy does not identify the use of 2 point restraints, a least restrictive restraint.