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Based on interview and record review, the facility failed to ensure the Condition of Participation for Patient Rights was met as evidenced by:

1. The facility failed to ensure one of 30 sampled patients (Patient 1) exercised her (Patient 1) right to use the telephone, in accordance with the facility's policies and procedures regarding denial of patient rights (ethical principles that apply to patient care. Example: the right to receive care in a safe environment). This deficient practice resulted in a violation of Patient 1's right to use the telephone, and had the potential to result in psychological harm. (Refer to A - 0129)

2.a The facility failed to ensure one of 30 sampled patients (Patient 1) was free from physical abuse (intentional bodily injury), when a registered nurse (RN 1) forcefully pushed Patient 1 against the wall and brought Patient 1 down to the floor face down. This deficient practice resulted in Patient 1 crying and sustaining a cut and bleeding from the chin. (Refer to A-0145)

2.b. The facility failed to immediately remove Registered Nurse (RN) 1 from the patient care area, in accordance with the facility's policies and procedures regarding abuse (intentional maltreatment of an individual that may cause physical or psychological injury), after RN 1 forcefully pushed one of 30 sampled patients (Patient 1) against the wall and onto the floor, then allowing RN 1 to finish his (RN 1) shift following the incident. This deficient practice had the potential to place other patients at risk for physical abuse from RN 1. (Refer to A-0145)

2.c. The facility failed to investigate a suspected physical abuse inflicted on one of 30 sampled patients (Patient 1) by Registered Nurse (RN) 1 in accordance with the facility's policy and procedure regarding abuse detection, prevention and interventions. This deficient practice had the potential for abuse to go unidentified and corrective actions not to be implemented, thus compromising patient safety. (Refer to A-0145)

3. The facility failed to provide abuse (intentional maltreatment of an individual that may cause physical or psychological injury) training for two of the five sampled staff members (Registered Nurse [RN] 1 and Certified Nurse Assistant [CNA] 1), in accordance with the facility's policies and procedures regarding abuse training. This deficient practice had the potential for staff not to be informed of abuse, neglect, and related reporting requirements, including prevention, intervention, and detection, thus could potentially compromise patient safety. (Refer to A - 0145)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality healthcare in a safe environment and potentially placing patients at risk for physical abuse.

Based on interview and record review, the Governing Body failed to ensure the Nursing Services Department provided oversight over contracted services for temporary clinical staffing in accordance with the facility's Corporate Bylaws regarding contracted services for one of five sampled contracted staffing agencies (SA1).

This deficient practice had the potential to compromise quality care and patient safety when contracted staff (registry personnel such as Registered Nurses and Certified Nursing Assistants) do not have the necessary training such as abuse (intentional maltreatment of an individual that may cause physical or psychological injury) prevention and intervention to manage patients.

Findings:

During a concurrent interview and record review on 3/7/2024 at 12:32 p.m. with Chief Human Resources Officer (CHRO), the facility's list of five contracted staffing agencies' services was reviewed. The facility was not able to locate a staffing agency contract for one temporary staffing service provider. CHRO stated, nursing chief officer (CNO) is responsible for overseeing all nursing staffing contracts. Each facility's contract with a service provider must contain delineation of contractor and the facility's' responsibilities in regard to the provision of care, obligations, and terms for both parties to abide. CHRO further stated, the facility must retain all contracts with all service providers.

During an interview on 3/8/2024 at 9:37 a.m. with Chief Finance Officer (CFO), CFO stated, the Human Resources (HR) department is ultimately responsible for renewing contracts, forwarding contracts to the Governing Body for review and approval, and the Finance department is responsible for storing all contracts, keeping track of contract renewal dates in coordination with the discipline involved by the services provided. CFO stated, for instance, all nursing contracts and clinical specialty contracts are referred to the CNO, who is ultimately responsible for the oversight for all nursing services, including staff competence and training.

During a concurrent interview and record review on 3/8/2024 at 2:56 p.m. with CFO, Certified Nursing Assistant's (CNA 1) personnel file was reviewed. CFO stated, CNA 1 was a temporary employee, whose services were provided by one of the contracted temporary staffing agencies. CNA 1 did not have "Abuse and Neglect" training on file (All healthcare workers are obligated to complete Mandated Reporters "Abuse and Neglect" training, which can include child abuse, domestic abuse, and elder abuse) as required by the facility's policy and procedures and State regulation. CFO further stated, CNO is responsible for overseeing nursing services, including competence and training.

During an interview on 3/8/2024 at 9:51 a.m. with the Chief Nursing Officer (CNO), the CNO stated, the facility was not able to locate the contract with one contractor providing temporary staffing services. The CNO was also not able to state the agreement's terms and conditions of the contract, including but not limited to delineation of contractor and facility's responsibilities with regards to staff competence and training.

During a review of the facility's Governing Body meeting minutes, no records were found of assessments of the services of the services provided under contract.

During a review of the facility's Corporate Bylaws (define the structure and responsibilities of the member organization), dated 2/12/2021, the Bylaws indicated, the Governing Body is responsible for ensuring all contracts contain the appropriate provisions with regards to the activities to be performed, time, schedules, and policies and procedures to be followed in carrying out the agreement, and the maximum amount for which the organization may become liable to the contractor under the agreement; the contract will include the necessary administrative, contractual, and termination provisions in the event of breach of contract by the contractor.

Based on interview and record review, the facility failed to ensure one of 30 sampled patients (Patient 1) exercised her (Patient 1) right to use the telephone, in accordance with the facility's policies and procedures regarding denial of patient rights.

This deficient practice resulted in a violation of Patient 1's right to use the telephone, which had the potential to result in psychological harm.

Findings:

During a review on 3/4/2024 at 2:58 p.m. with the Chief Nursing Officer (CNO), of the facility's video recording (with no audio), dated 1/17/2024, beginning at 1:46 p.m., the video captured the following:

At 1:46 p.m., Patient 1 was using the pay phone by the nursing station with a security guard (SG 1) and a certified nursing assistant (CNA 1) present. The video indicated RN 1 walked to Patient 1 three (3) times and exchanged words with Patient 1.

At 1:48 p.m., RN 1 walked back to Patient 1 the fourth time and hung-up Patient 1's phone. RN 1 and Patient 1 exchanged words. SG 1 physically separated RN 1 and Patient 1.

During an interview on 3/4/2024 at 3 p.m. with the Chief Nursing Officer (CNO), CNO stated the following: The CNO was notified only on 1/20/2024 about the incident involving physical abuse (intentional bodily injury) of Patient 1 that occurred on 1/17/2021. The CNO reviewed the video footage provided by the Security Guard (SG 1) on 1/20/2024. CNO stated, "He (RN 1) was abusive." There was no reason for RN 1 to interact with Patient 1 while Patient 1 was talking on the phone. RN 1 aggravated Patient 1 by hanging up the phone which escalated the situation. The CNO said RN 1 violated Patient 1's right to use the phone.

During a concurrent interview and record review on 3/7/2024 at 12:43 p.m. with Registered Nurse (RN) 2, RN 2 stated there was no documentation in Patient 1's medical record to indicate that there was a reason for Patient 1 to be denied the right to use the telephone.

During a review of the facility's policy and procedure (P&P) titled, "Patient Rights Policy and Notification," dated 1/2022, the P&P indicated the following: Patient on the Hospital's Acute Inpatient Units the following rights must be upheld and can only be denied when good cause exist (See "Denial of Rights") ...The right to have reasonable access to telephones, both to make and receive confidential calls.

During a review of the facility's policy and procedure (P&P) titled, "Denial of Patient Rights," dated 1/2022, the P&P indicated the following: The Hospital's Board of Directors has adopted the Mental Health Patient Rights of the State of California including when it is acceptable to deny a patient their rights. Under California Law the reason used to justify the denial of rights must be related to the specific right denied. Good cause for denial exists when exercise of the right would cause: Injury to that person, or a serious infringement on the rights of others, or serious damage to the facility and there is no less restrictive way of protecting the interest specified in the above referenced exception.

Based on interview and record review, the facility failed to:

1.a. Ensure one of 30 sampled patients (Patient 1) was free from physical abuse (intentional bodily injury), when a registered nurse (RN 1) forcefully pushed Patient 1 against the wall and brought Patient 1 down to the floor face down. This deficient practice resulted in Patient 1 crying and sustaining a cut and bleeding from the chin.

1.b. Immediately remove Registered Nurse (RN) 1 from the patient care area, in accordance with the facility's policies and procedures regarding abuse (intentional maltreatment of an individual that may cause physical or psychological injury), after RN 1 forcefully pushed one of 30 sampled patients (Patient 1) against the wall and onto the floor, then allowing RN 1 to finish his (RN 1) shift following the incident. This deficient practice had the potential to place other patients at risk for physical abuse due to the continued presence of the suspected abuser in the unit.

1.c. Investigate a suspected physical abuse inflicted on one of 30 sampled patients (Patient 1) by Registered Nurse (RN) 1 in accordance with the facility's policy and procedure regarding abuse detection, prevention and interventions. This deficient practice had the potential for abuse to go unidentified and corrective actions not to be implemented, thus compromising patient safety.

2. Provide abuse (intentional maltreatment of an individual that may cause physical or psychological injury) training for two of the five sampled staff members (Registered Nurse [RN] 1 and Certified Nurse Assistant [CNA] 1), in accordance with the facility's policies and procedures regarding abuse training and de-escalation techniques. This deficient practice had the potential for staff not to be informed of abuse, neglect, and related reporting requirements, including prevention, intervention, and detection, which could potentially compromise patient safety.

On 3/5/2024 at 3:53 p.m., the survey team called an Immediate Jeopardy (IJ, a situation in which the facility's non-compliance with one or more requirements has caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient) in the presence of the Chief Nursing Officer (CNO), the Director of Nursing (DON), and the Chief Quality Officer (CQO). Patient 1 was admitted to the facility on 1/10/2024 on a 5150-hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation) for being a danger to others (DTO). Patient 1's diagnosis included mood disorder (marked disruptions in emotions). On 1/17/2024 at 1:46 p.m., Patient 1 was physically abused (an intentional bodily injury) by Registered Nurse (RN 1) when RN 1 hung up the phone during Patient 1's telephone call followed by a verbal confrontation between RN 1 and Patient 1. Then RN 1 twisted Patient 1's arm while leading Patient 1 to her (Patient 1) room, then forcefully pushing Patient 1 against the wall and onto the floor, face down with Patient 1 sustaining a cut to the chin. Patient 1 was bleeding from a cut to the chin that was sustained during the incident. Patient 1 was crying and stated she (Patient 1) was "hurt." The incident was not immediately investigated by the facility and RN 1 was allowed to finish his (RN 1) shift at 7:30 p.m., placing other patients at risk for physical abuse. The facility made a request to the nursing registry for RN 1 not return to the facility on 1/20/2024, after reviewing the video footage, three days after the incident.

On 3/8/2024 at 3:36 p.m., the IJ was removed in the presence of the CNO, DON, CQO, and the Chief Medical Officer (CMO) after the facility submitted an acceptable IJ Removal Plan (interventions to correct the deficient practice). The elements of the IJ Removal Plan were verified and confirmed through observations, interview, and record reviews. The IJ Removal Plan included the following: All staff on duty on the clinical units would attend an in-service and required to read and sign that they understand the policies regarding Patient Abuse and Patient Rights (ethical principles that apply to patient care. Example: the right to receive care in a safe environment). If a staff observes a patient being physically abused, the staff is to stop the abuse by getting the abuser's attention and tell the abuser in a loud voice to stop and step away from the patient (victim). Staff has to alert the charge nurse or supervisor of the situation. The Supervisor immediately initiates an investigation of the incident. The Supervisor obtains a statement from the abuser and immediately removes the abuser from the patient care area.

Findings:

1.a. During a record review on 3/4/2024 at 2:58 p.m. with the Chief Nursing Officer (CNO), of the facility's video recording (with no audio), dated 1/17/2024 beginning at 1:46 p.m., the video captured the following:

At 1:46 p.m., Patient 1 was using the pay phone by the nursing station with a security guard (SG 1) and a certified nursing assistant (CNA 1) present, who was assigned as a sitter (supervise patients and alerts nurses and other healthcare professionals when needed) for Patient 1. The video indicated RN 1 walked up to Patient 1 three (3) times and exchanged words with Patient 1.

At 1:48 p.m., RN 1 walked back to Patient 1 the fourth time and hung-up Patient 1's phone. RN 1 and Patient 1 exchanged words. SG 1 separated RN 1 and Patient 1.

At 1:49 p.m., RN 1 grabbed Patient 1's right arm, twisted to her (Patient 1) back and walked to another nursing unit. RN 1 pushed Patient 1's body against the wall and brought Patient 1 down to the floor. There was blood on the floor after Patient 1 hit the floor facing down. RN 1 continued to restrain Patient 1's arms behind her (Patient 1) back while Patient 1 was facing down. RN 1 held Patient'1 left arm and SG 1 held Patient 1's right arm while walking Patient 1 to seclusion room (used for involuntary confinement of a patient alone in a room).

At 1:53 p.m., RN 1 let go of Patient 1's left arm after Patient 1 was placed in a seclusion room.

During an interview on 3/4/2024 at 3 p.m. with the Chief Nursing Officer (CNO), CNO stated the following: The CNO was notified by Security Guard (SG 1) only on 1/20/2024 about an incident involving physical abuse of Patient 1 inflicted by Registered Nurse (RN) 1 that occurred on 1/17/2024. CNO viewed the video footage of the incident, dated 1/17/20241 at 1:46 p.m., provided by SG 1 on 1/20/2024. CNO stated, "He (RN 1) was abusive." There was no reason for RN 1 to interact with Patient 1 while Patient 1 was talking on the phone. RN 1 aggravated Patient 1 by hanging up the phone which escalated the situation. There was no reason for RN 1 to slam Patient 1 against the wall and take Patient 1 onto the floor. RN 1 took Patient 1 down too roughly and hurt Patient 1's chin. CNO said Patient 1 was bleeding from her chin. CNO said RN 1 continued his (RN 1) shift until 7:30 p.m. that day, placing other patients at risk for physical abuse. CNO stated the facility notified RN 1's registry company and requested for RN 1 not to return to the facility on 1/20/2024.

During an interview on 3/4/2024 at 3:50 p.m. with charge nurse (CN 1), CN 1 stated the following: CN 1 watched the video footage dated 1/17/2024 and stated RN 1's behavior was inappropriate, and intentional, it looked like physical abuse. RN 1 used unnecessary force when RN 1 slammed Patient 1 against the wall then both (RN 1 and Patient 1) fell onto the floor. CN 1 stated Patient 1 landed on the floor facing down and observed blood on the floor. CN 1 said she (CN 1) witnessed RN 1 continued to hold down Patient 1. CN 1 stated she (CN 1) told RN 1 to let go of Patient 1, but RN 1 continued to hold down Patient 1 even though Patient 1 was calm. There was no need for RN 1 to touch Patient 1 because RN 1 was not assigned to Patient 1. CN 1 stated the house supervisor (HS 1) was present during the end of the incident and thought HS 1 would investigate the incident.

During an interview on 3/5/2024 at 9:51 a.m. with certified nursing assistant (CNA) 1, CNA 1 stated the following: CNA 1 was sitting for Patient 1 on 1/17/2024. Patient 1 required a sitter (supervise patients and alerts nurses and other healthcare professionals when needed) for safety reasons. Before the incident, Patient 1 was talking loudly on the phone but did not disturb other patients. RN 1 repeatedly told Patient 1 to lower her (Patient 1) voice when talking on the phone otherwise he (RN 1) would hang up the phone. CNA 1 told RN 1 that she (CNA 1) was sitting for Patient 1 and she (CNA 1) would handle Patient 1. RN 1 then approached Patient 1 and hung up the phone. Patient 1 got upset and both (RN 1 and Patient 1) engaged in a verbal argument.

SG 1 and CNA 1 tried to de-escalate (first-line response to potential violence and aggression) the situation and physically separated RN 1 and Patient 1. RN 1 grabbed Patient 1's arm while walking Patient 1 back to her (Patient 1) room. RN 1 then forcefully pushed Patient 1 against the wall and then forcibly took her down onto the floor. CNA 1 told RN 1 to stop but RN 1 continued to hold Patient 1 facing down on the floor with both arms behind her (Patient 1) back. Patient 1 sustained a cut on her (Patient 1) chin and it (chin) was bleeding. Patient 1 was crying and said she (Patient 1) was hurt. RN 1 was physically aggressive towards Patient 1 and she (CNA 1) considered it to be physical abuse.

During a review of Patient 1's Face Sheet (a document that gives a patient's information at a quick glance), the Face sheet indicated Patient 1 was admitted to the facility on 1/10/2024 on a 5150-hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation) due to danger to others (Patient 1 was being aggressive with parents which prompted admission to the facility).

During a review of Patient 1's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 1/11/2024 at 10:25 p.m., the H&P indicated the following: Patient (Patient 1), "admitted on 5150 (hold) after being aggressive with parents ..."

During a review of Patient 1's "Psychiatric Evaluation," dated 1/11/2024, the Psychiatric Evaluation indicated Patient 1's admitting diagnoses included mood disorder (marked disruptions in emotion), alcohol use disorder (uncontrolled drinking of alcohol), and cannabis use disorder (uncontrolled use of marijuana).

During a review of Patient 1's "Nursing Progress Note," dated 1/17/2024 at 6:44 p.m., the progress note indicated the following: At around 1 p.m. ... "In the process of performing the takedown (by RN 1), the pt (Patient 1) ensured an injury "cut" to the lower aspect of her chin. Injury was noted as being superficial and approximately 1 inch in length. Pt (Patient 1) was further assessed, and first aid provided."

During a review of the facility's policy and procedure (P&P) titled, "Patient Abuse," dated 2/2024, the P&P indicated the following: The Hospital "recognizes the rights of all patients to be free from all forms of abuse, neglect (as a form of abuse) and harassment whether from staff, other patients, or visitors. The hospital is required to ensure that patients are free from all forms of abuse, neglect, or harassment ...Abuse - the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, or mental anguish ...This policy applies to all employees ... 2. Identify. The hospital creates and maintains a proactive approach to identify events and occurrences that may constitute or contribute to abuse and neglect.

1.b. During an interview, on 3/4/2024 at 3 p.m. with the Chief Nursing Officer (CNO), CNO stated the following: The CNO was notified by Security Guard (SG 1) only on 1/20/2024 about an incident involving physical abuse of Patient 1 inflicted by Registered Nurse (RN) 1 that occurred on 1/17/2024 at 1:46 p.m. CNO stated RN 1 continued his (RN 1) shift until 7:30 p.m. on 1/17/2024, placing other patients at risk for physical abuse. CNO stated the facility notified RN 1's registry company and requested for RN 1 not to return to the facility on 1/20/2024, 3 days after the incident on 1/17/2024. The CNO also said that RN 1 should have been immediately removed from the patient care area to protect the patients, and an investigation should have been initiated immediately following the incident of physical abuse.

During an interview on 3/5/2024 at 10:29 a.m. with the executive assistant (EA), EA stated the following: RN 1's last day of work at the facility was 1/17/2024 from 7 a.m. to 7:30 p.m. EA called the nursing registry on 1/20/2024 to request for RN 1 not to return to the facility.

During a review of the facility's policy and procedure (P&P) titled, "Patient Abuse," dated 2/2024, the P&P indicated the following: The hospital creates and maintains a proactive approach to identify events and occurrences that may constitute or contribute to abuse and neglect. 4. Protect. The hospital protects patients from abuse during investigation of any allegation of abuse ... How to protect patients in the event of an allegation of abuse, neglect, or harassment. Any employee that has been accused of or alleged to have committed an act of abuse ...can expect the following: ...The employee against whom the allegation has been made will be immediately placed on unpaid leave while the investigation is taking place.

1.c. During an interview on 3/4/2024 at 3 p.m. with the Chief Nursing Officer (CNO), the CNO stated the following: The CNO was notified by SG 1 only on 1/20/2024 about the incident involving physical abuse of Patient 1 by RN 1 that occurred on 1/17/2024. The CNO also said an investigation should have been initiated immediately by the supervisor on 1/17/2024.

During an interview on 3/4/2024 at 3:50 p.m. with charge nurse (CN) 1, CN 1 stated the following: CN 1 watched the video footage dated 1/17/2024 and stated RN 1's behavior was inappropriate, and intentional, it looked like physical abuse. CN 1 said that RN 1 told her (CN 1) his (RN 1) version of the incident but after watching the video recording, CN 1 determined RN 1's account of the incident was incorrect, because Patient 1 was not resisting or fighting back. CN 1 stated she (CN 1) did not interview any other staff who witnessed the incident. CN 1 completed report of the incident but did not further investigate. CN 1 said the house supervisor (HS 1) was present during the end of the incident and she (CN 1) thought HS 1 would investigate the incident.

During an interview on 3/8/2024 at 9:45 a.m. with the Chief Quality Officer (CQO), the CQO stated she (CQO) became aware of the allegation of abuse on 1/20/2024 and reviewed the video recording dated 1/17/2024. The CQO stated that after viewing the video, the facility notified RN 1's staffing agency that RN 1 was not to return to the facility. In addition, the facility reported the alleged abuse of RN 1 towards Patient 1 to the Department. The CQO stated that the investigation of the incident (abuse of Patient 1) consisted of watching the video only. The facility did not interview staff who witnessed the incident. The CQO said the incident should have been thoroughly investigated.

During a review of the facility's policy and procedure (P&P) titled, "Patient Abuse," dated 2/2024, the P&P indicated the following: The Hospital "recognizes the rights of all patients to be free from all forms of abuse, neglect (as a form of abuse) and harassment whether from staff, other patients, or visitors. The hospital ensures that in a timely manner and thorough manner all allegations of abuse ...receive an objective investigation.

2. During a concurrent interview and record review on 03/06/2024 at 12:45 p.m. with the Human Resources Coordinator (HRC), the Chief Quality Officer (CQO), and the Chief Nursing Officer (CNO), five staff personnel files were reviewed. On questioning about the types of training necessary for all the employees handling direct patient care, the HRC stated that the necessary trainings are called handle with care (HWC- a training that teaches the staff how to recognize escalating conflict/tension and how to use their relationship to assist the patient to regain control of and redirect their tension into constructive and positive channels) and the Crisis Prevention & Intervention (CPI, a training designed to teach staff regarding verbal and physical methods of preventing violence and injury when dealing with upset patients). Upon review of the files, the HRC verified that Registered Nurse (RN) 1 and Certified Nursing Assistant (CNA) 1 had not completed their HWC & CPI trainings, which are part of the staff's abuse training requirements.

During a concurrent interview and review of RN 1 and CNA 1's personnel files, on 3/06/2024 at 12:45 p.m., with the HRC, CNO, and the CQO, the files indicated the following:

RN 1 had no record of restraint (devices that limit a patient's movement) training-HWC, nor CPI is on file. On questioning about the importance of providing adequate training to the staff, CQO stated that everyone needs to have training in place. In addition, the CNO stated "according to P&P, RN 1 needed to be trained here (to be provided training by the facility regarding restraints use, HWC and CPI trainings)." CNO stated that RN 1 is a contracted employee through an agency.

CNA 1's personnel file did not contain the necessary training(s). CNA 1 did not have the HWC completed nor filed. HRC stated that CNA 1 should have completed HWC training as it was necessary to handle patients and prevent instances of abuse. CNO stated that CNA 1 was a contracted employee through an agency.

During a review of the facility's policy and procedure (P&P) titled, "Patient Abuse," dated 02/2024, the P&P indicated, "Train. The hospital during its orientation program, and through ongoing training program, provides all employees with information regarding abuse and neglect, and related reporting requirements, including prevention, intervention, and detection."

Based on interview and record review, the facility's Quality Assurance and Performance Improvement (QAPI, a process used to ensure services are meeting quality standards and assuring patient care reaches a certain level) department failed to perform analysis on a patient safety event (an event, incident, or condition that could have resulted or did resulted in harm to a patient) for one of 30 sampled patients (Patient 1) after a Registered Nurse (RN) 1 physically abused (intentional bodily injury) Patient 1.

This deficient practice had the potential to put other patients at risk for physical abuse by staff as staff had lack of training on how to intervene and to report when witnessing another staff physically abusing a patient.

Findings:

During a review of Patient 1's Face Sheet (a document that gives a patient's information at a quick glance), the Face sheet indicated Patient 1 was admitted to the facility on 1/10/2024 on a 5150-hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) due to danger to others.

During a review of Patient 1's "Psychiatric Evaluation," dated 1/11/2024, the Psychiatric Evaluation indicated Patient 1's admitting diagnoses included mood disorder (marked disruptions in emotion), alcohol use disorder (uncontrolled drinking of alcohol), and cannabis use disorder (uncontrolled use of marijuana).

During a review on 3/4/2024 at 2:58 p.m. with the Chief Nursing Officer (CNO), of the facility's video recording (with no audio), dated 1/17/2024 beginning at 1:46 p.m., the video captured the following:

At 1:46 p.m., Patient 1 was using the pay phone by the nursing station with a security guard (SG 1) and a certified nursing assistant (CNA 1) present. The video indicated RN 1 walked to Patient 1 three (3) times and exchanged words with Patient 1.

At 1:48 p.m., RN 1 walked to Patient 1 the fourth time and hung-up Patient 1's phone. RN 1 and Patient 1 exchanged words. SG 1 physically separated RN 1 and Patient 1.

At 1:49 p.m., RN 1 grabbed Patient 1's right arm, twisted to her (Patient 1) back and walked to another nursing unit. RN 1 pushed Patient 1's body against the wall and brought Patient 1 down to the floor. There was blood on the floor after Patient 1 hit the floor facing down. RN 1 continued to restrain Patient 1's arms behind her (Patient 1) back while Patient 1 was facing down. RN 1 held Patient'1 left arm and SG 1 held Patient 1's right arm while walking Patient 1 to seclusion room (used for involuntary confinement of a patient alone in a room).

At 1:53 p.m., RN 1 let go of Patient 1's left arm after Patient 1 was placed in a seclusion room.

During an interview on 3/4/2024 at 3 p.m. with the Chief Nursing Officer (CNO), CNO stated the following: CNO was notified about the incident involving physical abuse of Patient 1 that occurred on 1/17/2024. The CNO reviewed the video footage provided by the Security Guard (SG 1) on 1/20/2024. CNO stated, "He (RN 1) was abusive." There was no reason for RN 1 to interact with Patient 1 while Patient 1 was talking on the phone. RN 1 aggravated Patient 1 by hanging up the phone which escalated the situation. There was no reason for RN 1 to slam Patient 1 against the wall and take Patient 1 onto the floor. RN 1 took Patient 1 down too roughly and hurt Patient 1's chin. CNO stated Patient 1 was bleeding from her chin. RN 1 continued his (RN 1) shift until 7:30 p.m. that day, placing other patients at risk for physical abuse. CNO stated the facility notified RN 1's registry company and requested for RN 1 not to return to the facility on 1/20/2024.

During an interview on 3/8/2024 at 9:53 a.m. with the Chief Quality Officer (CQO), CQO stated the following: she (CQO) did not perform root cause analysis (RCA, team process to identify root cause of an event that resulted in an undesired outcome and develop corrective actions) for the abuse because the facility terminated RN 1 by informing RN 1's registry company not to send RN 1 back to the facility anymore. The facility did not thoroughly investigate and did not talk to each individual staff who witnessed the abuse after the discovery. RCA should have been done so that the facility could identify the root cause problem for this abuse. The root cause problem was that the staff had lack of training on how to intervene when witnessing patient abuse by another staff and to report patient abuse to the immediate supervisor. The staff did not seem to be aware that they were responsible for speaking up when they felt a patient was being hurt by another staff member.

During an interview on 3/8/2024 at 10:15 a.m. with the Chief Nursing Officer (CNO), CNO stated the facility was currently in the process of training staff on how to intervene when witnessing patient abuse by another staff and to report to the immediate supervisor.

During a review of the facility's Quality Management Plan (QAPI Plan), dated 09/2022, the QAPI plan indicated, "The Quality Management Program is designed to monitor and evaluate the quality, appropriateness, effectiveness of, and methods by which healthcare and services are delivered to [facility] members ... The Quality Management Committee will address the issues that are identified, by analyzing for effectiveness of the quality improvement activities and ensuring that the improvement is on-going. [the facility] will utilize the Corrective and Preventative Action Process/program to identify root causes, preventative measures and remedies/resolutions."

During a review of the facility's policy and procedure (P&P) titled, "Patient Abuse," dated 02/2024, "[the facility] recognized the rights of all patients to be free from all forms of abuse, neglect and harassment whether from staff, other patients, or visitors. The hospital is required to ensure that patients are free from all forms of abuse, neglect or harassment and has put mechanisms/methods in place to accomplish this requirement ... [the facility] requires that any incident of abuse, neglect, or harassment are reported and analyzed, and appropriate corrective, remedial and/or disciplinary action occurs."