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.


Based on interview and record review, the facility failed to ensure staff competency for the safe management of disruptive and assaultive behavior for 1 (staff G) of 3 nursing staff assigned care to patients resulting in the inability to assure competent care was provided to patient #1. Findings include:

A review of the closed medical record for patient #1 was conducted on 1/7/19 at 1330 and revealed the following:
Patient #1 was admitted on [DATE] with diagnoses that included Schizophrenia, paranoid. The patient was transferred for emergent care to an acute care facilty on 12/2/18 for a left lower extremity injury.

On 1/7/19 at approximately 1510, a review of the facilty's complaint and grievance logs was conducted with Recipient Rights Advisor (Staff B). Upon review it was revealed that an investigation of an incident that occured on 12/2/18 involving patient #1 and Staff G had been conducted. Staff B said it was brought to her attention that a patient (#1) had been restrained and was later sent to the hospital for a "possible dislocated foot."

Staff B said she reviewed camera surveillance footage, interviewed pertinent staff members and reviewed the patient's medical record. Staff B said she did not interview patient (#1), because he had been transferred out to the hospital. She stated, "we usually don't contact patients once they are transferred out."

Staff B explained that she concluded that events captured on film involving the patient (#1) and Staff G and her subsequent investigation did not substantiate that the patient's injury was related to incident involving the patient and Staff G.

Staff B explained she forwarded her summary and recommendations to Human Resource department on 12/7/18.

On 1/8/19 at 0925 an interview was conducted with Staff G while accompanied by the Chief Nursing Officer (CNO). He explained he was a "Mental Health Technician" (MHT). He said he'd worked for the facilty for almost 5 years. He confirmed that he was working today. He said he recalled patient #1. Staff G said he worked a double shift on 12/2/18. According to Staff G patient #1 had been "aggressive that whole day" with 2 other patients and with 2 other staff members. He said he remembered that the patient #1 had thrown coffee on another MHT (Staff M) on the same day.

When asked to explain if he (Staff G) had ever had to restrain the patient or use physical force on the patient (#1) Staff G said he had not. Additionally, Staff G was asked if he had received any training on abuse prevention, recognition or behavior management. Staff G said his last annual training was about six months ago. He said there may have been some informal training/reminders in between but he could not recall any particular dates.

On 1/8/19 an interview and review of personnel files was conducted with Human Resource Staff N. Staff N confirmed there were no disciplinary actions documented in Staff G's personnel file at that time. A review of Staff G's most recent competency revealed a score of 87 percent. The form documented all staff had to achieve a passing score of 90 (%) percent and a retake was required for not passing with a minimum score of 90 %.

When asked to explain if Staff G had completed a retake as indicated on the form, Staff N said "No", that's wrong the requirement. She said we changed the requirement to 80 percent. I just haven't changed the form yet.

On 1/8/19 at 1500 an interview was conducted with Staff M while accompanied by the Chief Nursing Officer. He explained he was a (MHT). He said he'd worked for the facility for almost 2 years. He said he recalled patient #1. He said he had only had 2 interactions with the patient ever. He said on the patient's admission (uneventful) and on the 12/2/18 (the date of the incident).

According to Staff M he was serving additional coffee to patients that were still in the dining room/dayroom sometime after dinner on 12/2/18. He said patient #1 quickly gulped his coffee down and got in line for another cup. Staff M said after he gave patient #1 a second cup of coffee for no reason the patient (#1) just threw the coffee on Staff M. Staff M said there were no other staff in the dining/day room at that time. He said he was not burned. He said he did not fill out an incident report either on that day. He said I checked myself, and got cleaned up. He said I wasn't injured. He said, "I should have filed an incident report, but I didn't."

When further quired Staff M said patient #1 continued to come at him on several times that day. Staff M said there had been a scuffle at one point. He said he never used an excessive force or causing any injury to patient #1. Staff M said the patient never mentioned any pain or injury to him.

On 1/8/19 at 1600 a review of video surveillance footage dated 12/2/18 was conducted with the Director of Quality and Risk Management Staff D. Staff D identified patient #1 and MHT's (G and Q) at that time and the following was revealed:

At 13:23:39: patient #1 was observed in the quiet room standing at the doorway attempting to exit.
At 13:23:43: Staff G was observed attempting to redirect patient #1.
At 13:23:44: patient #1 was observed as he took a swing at Staff G with his left hand. Staff G was observed as he grabbed patient #1's right hand first and then with both of his hands was observed as he grabbed toward the patient's shoulder/neck area.
At 13:23:45: Staff G was observed as he grabbed the patient's neck.

At that time Staff D was asked if Staff G responded correctly by grabbing patient #1 by the neck in response to the patient's actions. Staff D said no he did not. She said Staff G did not follow the facility's policy. Staff D said she had reviewed the surveillance video previously. She explained that she had personally shared her concerns with him (Staff G) on 12/18/18. Staff D said she told him that she would meet with him regarding CPI technique but had not yet to date. According to Staff D, Staff G had not viewed the video footage. Staff D offered no further explanation when asked to explain why Staff G had not been re-educated on the proper technique for CPI.

On 1/9/19 at 1145 a review of Staff G's time sheets was conducted with Staff N and revealed Staff G worked on the following dates and times:
On 12/8/18: 8 hours.
On 12/9/18: 13.50 hours.
On 12/11/18: 8 hours.
On 12/12/18: 1.75 hours.
On 12/13/18: 8 hours.
On 12/14/18: 8 hours.
On 12/16/18: 8 hours.
On 12/18/18: 8 hours.
On 12/19/18: 7.75 hours.
On 12/20/18: 7.5 hours
On 12/22/18: 8 hours.
On 12/25/18: 8 hours.
On 12/28/18: 8 hours.
On 12/31/18: 8 hours.

According to Staff N Staff G had not been re-educated on CPI (crisis prevention intervention). She said we had planned to meet with him yesterday but our "Lead Head MHT" was off. He's responsible for the training and re-training.

On 1/9/19 at 1500 Staff N provided an email from the Lead Head MHT dated 1/9/2019 at 1424 that said Staff G had been retrained on CPI technique. There was no further evidence that documented Staff G had been re-educated on CPI technique.

An interview was conducted with the CNO on 1/9/19 at 1600 regarding the aforementioned concerns. She explained Staff G should have been taken off the schedule until he was in-serviced on the proper technique for CPI.