Mercyone Des Moines Medical Center

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 51283 Based on policy review, medical record review, and interviews with staff, the Acute Care Hospital (ACH)’s administrative staff failed to ensure hospital staff adhered to applicable nursing policies and procedures for 1 of 14 sampled patients (Patient #11) who presented to the hospital for inpatient services from 4/12/25 to 5/30/25. This deficient practice resulted in a failure by staff to appropriately reposition Patient #11 (P11), a patient who presented to the ACH with stroke-like symptoms, in accordance with hospital policy and accepted standards of practice to prevent the development or worsening of pressure-related injuries. Findings include: 1. Review of the 12/2023 policy “Basic Care Management - Adults - General Nursing” revealed in part: a. “Purpose: To provide a guide for the basic care and management of all adult patients.” b. “Policy: Nursing care is provided according to nursing standards, policies, procedures, and protocols that are individualized to the patient.” c. “Intentional Rounding: Intentional Rounding is done hourly from [6:00 AM to 10:00 PM] and every 2 hours from [10:00 PM to 6:00 AM] to address the following: pain management; positioning; personal needs, especially toileting; personal environment; environmental safety.” 2. Review of Patient #11 (P11)’s 4/12/25 medical record revealed the following: a. On 4/12/25 at 3:52 PM, P11 presented to the ACH via ground ambulance with complaints of stroke-like symptoms, including left-sided weakness, slurred speech, and paresthesia (a sensation of tingling, “pins and needles,” or numbness), and a history of hypertension (elevated blood pressure), hyperlipidemia (elevated cholesterol), hypothyroidism (abnormally low thyroid activity), prior pulmonary embolism (a blood clot or other blockage of an artery in the lungs), and a history of tobacco use. b. Staff obtained an initial set of vital sign measurements, which revealed an elevated blood pressure (164/86 mmHg). The patient then underwent computed tomography (CT) imaging of the head, which revealed the presence of a middle cerebral artery (MCA) stroke. At 4:54 PM, staff administered Tenecteplase (TNK) (a medication used to dissolve blood clots) and placed the patient on tube feeding. At 9:00 PM, staff transferred the patient to the Critical Care Unit (CCU). c. On 4/15/25 from 6:57 PM to 10:59 PM, staff failed to reposition the patient. d. On 4/16/25 from 12:05 AM to 07:00 AM, staff failed to reposition the patient. e. On 4/18/25, from 6:00 AM to 3:40 PM, staff failed to reposition the patient. f. On 4/20/25 from 11:00 PM to 4/21/25 at 4:00 AM, staff failed to reposition the patient. g. On 4/21/25 from 4:00 AM to 12:00 PM, staff failed to reposition the patient. h. On 4/24/25 at 2:30 PM, staff discharged the patient. 3. During an interview on 6/5/25 at 1:15 PM, Staff N (Registered Nurse (RN)) reported hospital policy required staff to reposition patients at least once every two hours, or more frequently if indicated by the patient’s Braden Scale (an assessment utilized to assess patients’ risk of pressure ulcer development). Staff N reported staff would perform a Braden Scale assessment for each patient to identify risk factors for pressure sores and to inform preventive interventions (e.g., frequent repositioning), depending on the patient’s mobility, nutrition, moisture, ability to feel pain, and activity level. Staff N reported nursing staff and Patient Care Technicians (PCTs) shared responsibility for repositioning patients in accordance with hospital policy, as well as documenting said repositioning. 4. During an interview on 6/5/25 at 11:30 AM, Staff M (PCT) reported hospital policy required staff to reposition patients at a minimum of once every two hours. Staff M acknowledged P11’s medical record did not include evidence of bihourly repositioning, as required by hospital policy, during multiple periods of the hospitalization. 5. During an interview on 6/5/25 at 3:00 PM, Staff L (Interim Director) reported they expected staff to adhere to hospital policy requiring repositioning at a minimum of two hours, or more frequently if indicated by the patient’s condition. Staff L acknowledged staff documented two variances (deviations from expected standards of patient care) related to staff failures to reposition the patient, per hospital policy. Staff L identified five time periods in which staff failed to reposition P11 for periods of approximately 4 to 9 hours, including the following: on 4/15/25 from 6:57 PM to 10:59 PM, on 4/16/25 from 12:05 AM to 07:00 AM, on 4/18/25 from 6:00 AM to 3:40 PM, on 4/20/25 from 11:00 PM to 4/21/25 at 4:00 AM, and on 4/21/25 from 4:00 AM to 12:00 PM.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 51106 Based on document review, policy review, and interviews, the Acute Care Hospital (ACH)’s administrative staff failed to ensure hospital staff informed patients or their legal representative of their rights as a patient for 2 of 11 sampled patients (Patients #5 and #10) who presented to the ACH from 1/23/24 to 11/21/24. This deficient practice placed all incapacitated patients who received care at the ACH, including incapacitated patients, at risk of not having their rights as a patient amply protected and promoted. Findings include: 1. Review of the policy titled “Patient Rights and Responsibilities Policy” last reviewed January 2022 revealed in part: a. “[The hospital] will provide information to patients advising them of their rights and responsibilities.” b. “In the case of a patient who is incapacitated, when an individual presents to the hospital with an advance directive, medical power of attorney or similar document [such as legal guardian] executed by the patient and designating an individual to make medical decisions for the patient when incapacitated, then the hospital must, when presented with the document, provide the required notice of its policies to the designated representative.” c. “When a patient is incapacitated or otherwise unable to communicate his or her wishes, there is no written advance directive on file or presented, and an individual asserts that he or she is the patient’s spouse, domestic partner (whether or not formally established and including a same-sex domestic partner), parent (including someone who has stood in loco parentis for the patient who is a minor child), or other family member and thus is the patient’s representative, the hospital is expected to accept this assertion, without demanding supporting documentation, and provide the required notice to the individual.” 2. During an interview on 12/02/24 at 12:39 PM, Staff OO (Patient Access Director) reported that registration staff had a responsibility to ensure patients or their representative received the Patient Rights and Responsibilities information. Staff OO reported, in the case of an incapacitated patient, registration staff would initially wait to see if the patient’s family arrived. If no family arrived, then staff would look into the electronic medical record system to see if the patient had a power of attorney (POA). If the patient did not have a POA, then staff would contact the legal next of kin. Staff OO reported that registration staff would document any contact or contact attempts with the patient’s family or legal representative. 3. Review of Patient #5 (P5)’s 8/22/24 medical record revealed the following: a. P5 presented to the ACH on 8/22/24 for increased lethargy (lack of energy) and weakness. P5 had a history of dementia and resided in a nursing home. b. On 8/22/24 at 2:59 PM the emergency department (ED) physician documented they spoke with a family member, and they provided the phone number of the family member in their note. c. On 8/22/24 at 5:02 PM Staff PP Physician documented in the History and Physical (H&P) that P5 could not provide their own medical history and did not have family at their bedside at this time. d. Review of the medical record did not reveal evidence of registration staff informing the family member of the patient’s rights. e. During an interview on 12/02/24 at 12:39 PM with Staff OO (Patient Access Director), Staff OO acknowledged that registration staff did not document any attempts to contact P5’s legal representative to provide information regarding the patient’s rights. f. On 8/24/24 at 10:11 AM, hospital staff discharged P5 back to their nursing facility. 4. Review of the medical record Patient #10 (P10)’s 9/11/24 medical record revealed the following: a. P10 presented to the Acute Care Hospital on 9/11/24 after ingesting a foreign body. P10 had a history of schizophrenia and resided in a care facility. b. Review of documentation sent with the patient from the care facility to the hospital showed that P10 had a legal guardian and noted the contact information for the guardian. c. Review of the medical record did not reveal evidence of hospital staff informing the legal guardian of the patient’s rights. d. During an interview on 12/02/24 at 12:39 PM, Staff OO (Patient Access Director) Staff OO acknowledged that registration staff did not document any attempts to contact P10’s legal representative to provide notice of the patient’s rights. e. On 9/14/24, hospital staff discharged P10 back to their care facility.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 51283 Based on medical record review, review of hospital policy and staff interview, the acute hospital administration staff staff failed to follow their policies for care of patients in the clinical observation unit, failure to follow their policies for care of patients in the clinical observation unit resulted in the following: 1. hospital failed to ensure Patient #2, received care in a safe setting ( see A0144); and, 2. hospital staff inappropriate utilized restraint methods on patient #2 (see A0154, A0164, A0167). The cumulative effect of these systemic failures and deficient practices resulted in the acute hospitals administrative staffs inability to ensure the patient rights were maintained and were adequate to meet care needs for Patient #2.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 51283 Based on medical records review, review of hospital policy and staff interview, the acute hospital administration staff failed to separate an alleged abuser from all patients after a witnessed incident of abuse for 1 of 10 patients (Patient #2). Failure to provide care in a safe setting and remove an alleged abuser from all patients resulted in the alleged abuser continuing to have access to all other Critical Observation Unit (COU) patients seeking care after the allegation of abuse. This placed vulnerable patients at the risk for further incidents of abuse. Findings include: 1. Review of the policy number 2.37.13 “ Patient Rights and Responsibilities Policy”, reviewed last January 2022. Revealed in part: “...All (hospital) staff members who are mandatory reporters are responsible for the immediate management and reporting of situations involving alleged or suspected dependent adult abuse or neglect ... Freedom from abuse, financial or other exploitation, retaliation, humiliation, neglect ...” 2. Review of policy number 02.78.02 “ Suspected Dependent abuse and mandatory reporting policy” reviewed last February 2022. Revealed in part: “ ....Measures will be taken to separate the dependent adult and any other patients from the accused staff member, if known, until the investigation is complete ...If allegations of abuse or neglect occur involving a (hospital) patient by a (hospital) employee, staff are required to immediately notify the person in charge of his/her department or area ...” 3. Review of the documentation of the Hospital’s abuse investigation dated on 8/19/24, at 3:34 PM revealed an investigation into an alleged abuse to Patient #2 was initiated on 8/19/24 at 5:15 AM by RN C. It was reported to RN C that Patient #2 was being aggressive and violent, resulting in Mental Health Technician (Tech) B hitting Patient #2 in the face and pulling her hair. 4. Review of the medical record for Patient #2 revealed: a. Patient #2 was admitted to the Emergency Department (ED) on 8/10/24 at 11:36 PM and transferred to the Critical Observation Unit (COU) on 8/11/24 at 2:15 AM. b. ED Physician Y documented on 08/10/2024 at 11:56 AM Patient #2, with a history of autism, presented to the ED for evaluation of behavioral problems. Initially calm and redirectable, Patient #2 became agitated during the evaluation, attempted to escape, and tried to hit group home staff members present in the room, remaining agitated with violent behavior. ED Physician Y documented a lab work obtained per Telehealth Provider X request prior to psychiatric consultation. Patient #2 had impaired memory, limited vocabulary, impaired cognition, poor insight and judgment, and primarily responded to yes or no questions, often inaccurately. Patient #2 had a history of autism, intellectual disability, aggression, and was diagnosed with impulse control disorder and adjustment disorder with mixed disturbance of emotions and conduct. Reports indicated episodes of severe aggression, inability to perform activities of daily living, incontinence, and pain from a fracture. Patient #2 could walk, but complained of pain, used a wheelchair, and required one-to-one care on the unit. c. Psychiatric consultation occurred via Telehealth Provider X on 08/10/2024 at 06:03 PM for Patient #2, with documentation indicating a primary diagnosis of severe intellectual disabilities. The level of care recommendation was deferred, and placement was referred to social workers due to baseline struggles with aggression and elopement related to the intellectual disability. Treatment recommendations included residential placement for developmental disability, also deferred to social work. Pharmacological recommendations involved continuing Ativan and Zyprexa as needed for outbursts. d. Tech D documented on 08/17/2024 at 09:00 AM that Patient #2 hit, spat, screamed, and tried to break the computer at the nursing station. A phone call was placed to public safety for assistance. e. Tech D documented on 08/18/2024 at 09:00 AM that Patient #2 punched the staff, spat at them, and attempted to break the computer at the nursing station. At 4:40 PM, Patient #2 pulled the computer apart and became physical with staff for approximately one hour. Tech D reported being hit around 5:00 PM to the nursing staff. i. COU RN E documented on 08/18/2024 at 6:28 PM that Patient #2 was aggressive and hit the staff. Patient #2 was redirected multiple times without success and received as needed Clonazepam (medication used to treat psychosis and aggression) at 5:46 PM. 5. During an interview on 9/23/2024 at 2:00 PM, COU RN Supervisor (Supervisor for 4 West, COU) confirmed that the hospital became aware on 08/19/2024 at approximately 5:15 AM of an alleged abuse situation that took place on 08/18/2024 during the day shift involving Patient #2, Tech B, and Tech D. In this interview, COU RN Supervisor learned about the situation from Tech A. Tech A reported to COU RN Supervisor that Patient #2 exhibited aggressive and violent behavior, and Tech B responded by hitting Patient #2 in the face and pulling hair. Tech D reportedly witnessed the incident. COU RN Supervisor received screenshots of text messages via email from Tech A, which contained a portion of the conversation between Tech B and Tech A. 6. During an interview on 09/25/2024 at 3:00 PM, Tech B confirmed understanding abuse as knowingly putting hands on someone out of spite or anger that would cause harm. Tech B confirmed completing mandatory reporting for dependent adult abuse. Tech be recalled completing training on restraints with the Handle with Care program. Tech B recalled the weekend shifts from 7:00 AM to 7:00 PM on 08/17/2024 and 08/18/2024 were challenging. On 08/17/2024, Tech B placed a call to the local police department and the hospital ‘s public safety officers (PSOs). Tech B reported this call for assistance arose from the unsafe situation on the unit, with Patient #2’s aggression being unmanageable. Tech B felt unable to care for other patients or ensure their safety due to Patient #2’s outbursts. Tech B reported on 08/17/2024 COU RN HH unit could not log into the computer or the Pyxis (medication dispensing) machine to obtain medications for Patient #2 or other patients. Tech B recalled IT (information technology) and pharmacy were contacted to assist COU RN HH. Tech B attempted to reach COU RN Supervisor (Supervisor for 4 W, COU) on the phone but did not receive a return call. Tech B reported calling in efforts to seek guidance and instruction from COU RN Supervisor. Tech B confirmed being present in the room with PSO S and PSO R. Tech reported observing the techniques employed by the public service officers. Tech B recalled PSO R asked about the plan, but no plan of action or care could be provided. Tech B reported Patient #2 calmed down after taking medication. On 08/17/2024, Tech B recalled Patient #2 was placed in a hold utilizing the same technique observed earlier that morning. Tech B reported using the same hold observed from PSO S and PSO R earlier that morning after obtaining permission from COU RN HH to use the same technique. Tech B requested clarification about the difference between the hold used by PSOs and restraining Patient #2. Tech B recalled COU RN HH stated that the distinction between soft restraints and the hold used was merely semantic. Tech B reported COU RN HH advised that since Patient #2 was not being tied down and was not being harmed, using the hold observed by the PSO was permissible. Tech B recalled Patient #2 was held down by shoulders, arms, legs, and hips. Tech B reported using a hold on Patient #2 that was not in the COU training or policy. Tech B reported using this same technique for Patient #2 on 08/17/2024 and 08/18/2024. Conversations occurred with Patient #2 while in the hold, with Patient #2 squirming when hands rested on the hip, prompting reminders not to get up. Tech B reported using a stern tone to advise Patient #2 not to hit others. On 08/18/2024, Tech D was assigned to serve as the one-on-one staff for Patient #2, who remained very agitated throughout the shift. Tech B was assigned as the intake staff member on 08/18/2024. Tech B felt that Tech D was losing patience with Patient #2, who needed to leave the unit for about 20 minutes to take a break from the situation. During that time, one-on-one care was provided by Tech B until Tech D returned. Tech B reported COU RN E was aware of Patient #2’s agitated states and altercations with staff. Tech B recalled COU RN E witnessed Patient #2 attempting to break the computer and phone at the nursing station. Tech B explained spitting incidents occurred, with spit landing in Tech B’s eye, while distance was maintained by moving around to the other side of the nursing station. Tech B reported Patient #2 hands were held and Tech B’s fingers were placed over Patient #2’s mouth. Tech B reported telling Patient #2 sternly to stop. Time was spent in the lobby with Patient #2, assisting with hair care by Tech B. Tech B recalled COU RN E was aware of Patient #2’s aggression and did not assist either Tech B or Tech D. Tech B reported being punched by Patient #2 and was advised by COU RN E to complete a variance report. Tech B explained Patient #2 was placed in a hold, a restraint order was not needed since the Handle with Care program was used. Tech B recalled during the 08/18/2024 shift, an attempt was made to brush and braid Patient #2 hair. Tech B denied tugging on Patient #2 during that time. Tech B recalled Patient #2 having tangled and knotted hair. Tech B recalled being questioned by the COU RN Supervisor on events that took place on 08/18/2024. Tech B explained COU RN Supervisor placed Tech B on administrative leave. Tech B reported asking questions, but not getting answers. Tech B was unsure why this action was taken by the COU RN Supervisor . Tech B recalled the policies on the COU were not well understood or clear. Tech B reported communication and resources were not adequate to provide the care Patient #2 required. Tech B recalled being asked to perform duties outside of the job description. Tech B recalled a situation where Patient #2 needed a new incontinence pad. Tech B explained they do not change underwear, pads or help patients change clothing. Tech B expressed patients on the COU should be independent with care of daily living. Tech B explained when Patient #2 needed a new incontinence pad, one was provided. Tech B expressed telling Patient #2, they ( Patient #2) could do it without assistance as it was not the job of Tech B to change them. 7. During an interview on 09/24/2024 at 11:00 AM, Tech D confirmed completing mandatory reporting of a dependent adult and Handle with Care training. Tech D reported that the Handle with Care training included verbal de-escalation techniques and methods to hold a patient to prevent further injury to self or others. Tech D confirmed the training did not permit restraints that tie down a person’s arms. On 08/18/2024, Tech D was assigned as a one-on-one staff member for Patient #2. Tech D confirmed Tech B was working as an Intake staff member. Tech D confirmed Tech B slapped Patient #2 in the face with an open hand during an episode when Patient #2 spit at Tech B. Tech D reported standing next to Patient #2 during this alleged abuse, while Tech B stood on the opposite side of the nursing station desk when the slap occurred. Tech D confirmed that no verbal attempt was made to intervene. Tech D indicated that the appropriate intervention should have involved wearing a face shield and maintaining distance from Patient #2. Tech D stepped back when Patient #2 attempted to punch at the nursing station. Patient #2 was taken back to the bedroom to calm down and held down in bed twice for about five minutes each time. Patient #2 was restrained by the arms and shoulders. Tech D reported using a trained hold technique. Patient #2 could still move legs while being held down. Both Tech B and Tech D performed the holds on Patient #2. Patient #2 was “let up” and then held down again for another five minutes to prevent hitting staff until COU RN E arrived. COU RN E instructed Tech B and Tech D to release Patient #2. Tech D recalled that COU RN E witnessed Patient #2 being held down, but would often disappear from the unit during the shift. During the 08/18/2024 shift, Patient #2 attempted to bite Tech B, prompting Tech B to tug on Patient #2’s hair as an intervention to stop this behavior. Tech D recalled that Patient #2 sat beside Tech D on the bench while Tech B stood at a distance during this incident. Patient #2 did not come into contact with Tech B’s skin nor attempt to bite Tech D whom sat next to Patient #2. Tech D described the shift as difficult due to Patient #2’s aggression and other personal issues. Tech D recalled not reporting behaviors to COU RN Supervisor until COU RN Supervisor called Tech D the next morning. Tech D reported no disciplinary action was taken for actions Tech D reported doing on the 08/18/2024 work shift. Tech D recalled working all scheduled shifts since 08/18/2024. Tech D recalled no further education being provided by COU RN Supervisor since the 08/18/2024 incident. Tech D reported outside of being told to allow Patient #2 to break the computer and have a melt down no further advice or education has been provided. Tech D reported not feeling there was adequate staffing to meet the needs of Patient #2. 8. During an interview on 9/24/2024 10:31 AM, COU RN E confirmed Patient #2 was in an agitated state. COU RN E recalled Tech B was frustrated during the shift due to the behaviors of Patient #2. COU RN E recalled witnessed interactions between Patient #2, Tech B and Tech D were normal. COU RN E denied being aware of any level of confrontation or alleged abuse. 9. Review of the COU variance report revealed: a. Tech B documented on 08/18/2024 at 10:59 AM that Patient #2 hit Tech B in the face, and spit in Tech B’s face. Tech B documented Patient #2 was sternly grabbed by the hands and told the behavior was not okay. Tech B documented Patient #2 was forced to sit bad down in the wheelchair and held until calmed down enough to get Patient #2 into the bedroom. b. Tech B documented on 08/18/2024 at 11:34 AM Patient #2’s aggressive behavior. Tech B documented Patient #2’s hand were held as Patient #2 spit in Tech B’s eye. c. COU RN Supervisor documented on 08/20/2024 at 5:17 AM that Tech B slapped and pulled the hair of Patient #2. Tech B allegedly pinned Patient #2 down. Patient #2 had been aggressive and violent and Tech B reacted with these interventions. Patient #2 did not have any injuries noted as of 08/20/2024. 10. During an interview on 09/23/2024 at 1:00 PM, Tech A confirmed COU RN Supervisor received notification on 08/19/2024 at 5:15 AM regarding the text messages and verbal conversation between Tech A and Tech B, which took place on 08/18/2024 at approximately 3:00 PM and 7:00 PM. 11. The survey team reviewed the hospitals internal investigation document on 09/23/2024 of text message screenshots obtained during the hospital investigation confirmed that Tech B admitted to smacking Patient #2 in the mouth and stated that Patient #2 was made to perform her own incontinence care despite crying for help. Tech B also admitted in text messages to holding Patient #2’s hands down to the counter and pinning her in bed. a. On 08/19/2024 COU RN Supervisor was made aware of the situation by Tech A. Tech D informed COU RN Supervisor that Patient #2 was yelling, spitting and hitting staff. Tech D reported to COU RN Supervisor that Tech B got upset and hit Patient #2 in the face and later pulled Patient #2’s hair. b. On 8/19/24 Tech B was notified they were being placed on an unpaid administrative leave effective immediately pending the results of the investigation. c. On 8/21/24, COU RN Supervisor documented they called Tech D for a follow up conversation regarding previous statements. Tech D clarified that Tech B hit Patient #2 with an open hand on the left side of the mouth. Tech D recalled not seeing much of Patient #2’s hair being pulled. Tech D reported they had not witnessed Tech B behave in this manner before. Tech D also clarified that they were holding Patient #2’s arm down by their side. d. On 8/21/24 COU RN Supervisor documented speaking with Tech B by phone for a follow up conversation, and Tech B denied smacking Patient #2 in the mouth. Tech B stated to COU RN Supervisor they covered Patient #2’s mouth with a gloved hand due to spitting. Tech B denied depriving Patient #2 of personal care, however Tech B stated they do not put diapers on people. COU RN Supervisor reported Tech B stated they did hold Patient #2’s hands on the counter. COU RN Supervisor documented Tech B stated Patient #2 was held down in bed until Patient #2 calmed down. Tech B recalled they played with Patient #2’s hair. Tech B stated to COU RN Supervisor that they were holding Patient #2’s hair when they lunged at COU RN E. e. On 8/21/24, COU RN Supervisor had a follow-up phone conversation with COU RN E, who clarified what they witnessed was more of a redirection that had to include touching the patient versus a hold. COU RN E reported that verbal redirection occurred all day, multiple times a day, and COU RN E did not witness Tech B striking Patient #2, or pulling their hair. 12. During an interview on 09/30/2024 at 4:30 pm, COU RN Supervisor recalled being aware of 08/17/2024 events when PSO and local police were called. COU RN Supervisor acknowledged getting department variance reports, however did not recall Tech B completing one of the events that took place on 08/17/2024 or 08/18/2024. COU RN Supervisor recalled since Patient #2 has been on the unit, there had been a large number of reported violent and aggressive behaviors done by Patient #2 to staff members. COU RN Supervisor explained the COU did not have the resources Patient #2 required, and interventions staff tried did not work. COU RN Supervisor confirmed quality improvement had not done a risk assessment analysis, nor assisted in looking for solutions to the increased reported events involving Patient #2. COU RN Supervisor recalled Tech B was placed on administrative leave due to staff witnessing the alleged abuse, but Tech D remained on the schedule and allowed to work. COU RN Supervisor expressed feeling Tech D was new and was going off the training done by Tech B.”

“USE OF RESTRAINT OR SECLUSION CFR(s): 482.13(e) Patient Rights: Restraint or Seclusion. All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. This Standard is not met as evidenced by: 51283 Based on medical record review, review of hospital policy and staff interview, the acute hospital administration staff failed to identify a patient’s basic rights, ensure patient safety, and eliminate the inappropriate use of restraint or seclusion for 1 of 10 patients (Patient #2). Failure to provide basic rights to a patient prohibits them from receiving care in a safe setting and as well as fails to keep all patients free from all forms of abuse. Findings include: 1.Review of the policy number 14.49.17 “Restraints/Restraints Management,” Last Reviewed 10/2023, revealed in part: a. “PURPOSE: To provide the safe, appropriate and clinically justified use of restraint/restraints. To educate colleagues and medical staff ... on the philosophy that every patient has a right to be free from restraint/restraints. (The hospital) leadership supports a culture in which restraint/restraints and/or is only used in situations that promote medical healing or utilized in situations of imminent danger to patients, colleagues, self, or others when less restrictive interventions have been attempted ...” b. “Restraint/restraints: Any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. This includes any drug or medication when it is used as a restriction to manage the patient ’ s behavior or restrict the patient ’ s freedom of movement and is not a standard treatment or dosage for the patient ’ s condition...” c. “ ...Violent Behavioral Restraint/restraints: The restriction of patient movement for the management of violent self-behavior that jeopardizes the immediate physical safety of the patient, colleagues or others ...” d. “Restraint/restraints may only be used: To ensure the immediate safety of the patient and/or others and not as a means of coercion, discipline, convenience or retaliation by staff members; when less restrictive measures have been identified, attempted and found to be ineffective in protecting the patient and/or others from imminent harm ...” e. “ ...The use of restraint/restraints for the management of patient behavior is not considered a routine part of care and requires written modification to the individual’s plan of care ...” f. “ ...The use of restraint/restraints is used in accordance with a [Licensed Practitioners] (LP) order for ensuring clinical justification of restraint/restraints use for protecting the patient’s rights, dignity and well-being ...” g. “ ...A registered nurse (RN) may initiate restraint/restraints in advance of an LP ’ s order if self-harm, and/or danger to others is imminent ...” h. “ ... Orders: Initial Order; obtain order within 1 hour of restraint/restraints or initiation; must include type of restraint/restraints age specific time limit, and reason for use; and must be seen face-to-face by LP within 1 hour. The attending provider must be notified as soon as possible if they did not order the restraint/restraints ...” 2. During an interview on 09/23/2024 at 1:00 PM, Tech A confirmed COU RN Supervisor received notification on 08/19/2024 at 5:15 AM regarding the text messages and verbal conversation between Tech A and Tech B, which took place on 08/18/2024 at approximately 3:00 PM and 7:00 PM. 3.The survey team reviewed the hospitals internal investigation document on 09/23/2024 of text message screenshots obtained during the hospital investigation confirmed that Tech B admitted to smacking Patient #2 in the mouth. Tech B also admitted in text messages to holding Patient #2’s hands down to the counter and pinning her in bed. 4. During an interview on 09/24/2024 at 11:00 AM, Tech D reported that the Handle with Care training included verbal de-escalation techniques and methods to hold a patient to prevent further injury to self or others. Tech D confirmed the training did not permit restraints that tie down a person’s arms. Tech D confirmed Tech B slapped Patient #2 in the face with an open hand during an episode when Patient #2 spit at Tech B. Tech D reported standing next to Patient #2 during this alleged abuse, while Tech B stood on the opposite side of the nursing station desk when the slap occurred. Tech D confirmed that no verbal attempt was made to intervene. Tech D indicated that the appropriate intervention should have involved wearing a face shield and maintaining distance from Patient #2. Tech D stepped back when Patient #2 attempted to punch at the nursing station. Patient #2 was taken back to the bedroom to calm down and held down in bed twice for about five minutes each time. Patient #2 was restrained by the arms and shoulders. Tech D reported using a trained hold technique. Patient #2 could still move legs while being held down. Both Tech B and Tech D performed the holds on Patient #2. Patient #2 was “let up” and then held down again for another five minutes to prevent hitting staff until COU RN E arrived. COU RN E instructed Tech B and Tech D to release Patient #2. Tech D recalled that COU RN E witnessed Patient #2 being held down but would often disappear from the unit during the shift. During the 08/18/2024 shift, Patient #2 attempted to bite Tech B, prompting Tech B to tug on Patient #2’s hair as an intervention to stop this behavior. Tech D recalled that Patient #2 sat beside Tech D on the bench while Tech B stood at a distance during this incident. Patient #2 did not come into contact with Tech B’s skin nor attempt to bite Tech D whom sat next to Patient #2. Tech D described the shift as difficult due to Patient #2 ’ s aggression and other personal issues. 5. During an interview on 09/25/2024 at 3:00 PM, Tech B recalled completing training on restraints with the Handle with Care program. Tech B recalled the weekend shifts from 7:00 AM to 7:00 PM on 08/17/2024 and 08/18/2024 were challenging. On 08/17/2024, Tech B placed a call to the local police department and the hospital’s public safety officers. Tech B reported this call for assistance arose from the unsafe situation on the unit, with Patient #2’s aggression being unmanageable. Tech B felt unable to care for other patients or ensure their safety due to Patient #2’s outbursts. Tech B reported on 08/17/2024 COU RN HH unit could not log into the computer or the Pyxis (medication) machine to obtain medications for Patient #2 or other patients. Tech B recalled IT (Information Technology) and pharmacy were contacted to assist COU RN HH. Tech B attempted to reach COU RN Supervisor (Supervisor for 4W, COU) on the phone but did not receive a return call. Tech B reported calling in efforts to seek guidance and instruction from COU RN Supervisor . Tech B confirmed being present in the room with PSO (Public Safety Officer) S and PSO R. Tech reported observing the techniques employed by the public service officers. Tech B recalled PSO R asked about the plan, but no plan of action or care could be provided. Tech B reported Patient #2 calmed down after taking medication. On 08/17/2024, Tech B recalled Patient #2 was placed in a hold utilizing the same technique observed earlier that morning. Tech B reported using the same hold observed from PSO S and PSO R earlier that morning after obtaining permission from COU RN HH to use the same technique. Tech B requested clarification about the difference between the hold used by PSOs and restraining Patient #2. Tech B recalled COU RN HH stated that the distinction between soft restraints and the hold used was merely semantic. Tech B reported COU RN HH advised that since Patient #2 was not being tied down and was not being harmed, using the hold observed by the PSO was permissible. Tech B recalled Patient #2 was held down by shoulders, arms, legs, and hips. Tech B reported using a hold on Patient #2 that was not in the COU training or policy. Tech B reported using this same technique for Patient #2 on 08/17/2024 and 08/18/2024. Conversations occurred with Patient #2 while in the hold, with Patient #2 squirming when hands rested on the hip, prompting reminders not to get up. Tech B reported using a stern tone to advise Patient #2 not to hit others. On 08/18/2024, Tech D was assigned to serve as the one-on-one staff for Patient #2, who remained very agitated throughout the 7:00 AM to 7:00 PM shift. Tech B was assigned as the intake staff member on 08/18/2024. Tech B felt that Tech D was losing patience with Patient #2, who needed to leave the unit for about 20 minutes to take a break from the situation. During that time, one-on-one care was provided by Tech B until Tech D returned. Tech B reported COU RN E was aware of Patient #2’s agitated states and altercations with staff. Tech B recalled COU RN E witnessed Patient #2 attempting to break the computer and phone at the nursing station. Tech B explained spitting incidents occurred, with spit landing in Tech B’s eye, while distance was maintained by moving around to the other side of the nursing station. Tech B reported Patient #2 hands were held and Tech B’s fingers were placed over Patient #2’s mouth. Tech B reported telling Patient #2 sternly to stop. Time was spent in the lobby with Patient #2, assisting with hair care by Tech B. Tech B recalled COU RN E was aware of Patient #2’s aggression and did not assist either Tech B or Tech D. Tech B reported being punched by Patient #2 and was advised by COU RN E to complete a variance report. Tech B explained Patient #2 was placed in a hold, a restraint order was not needed since the Handle with Care program was used. Tech B recalled during the 08/18/2024 shift, an attempt was made to brush and braid Patient #2 hair. Tech B denied tugging on Patient #2 during that time. Tech B recalled Patient #2 having tangled and knotted hair. Tech B recalled the policies on the COU were not well understood or clear. 6. During an interview on 09/26/2024 at 12:25 PM with PSO R, confirmation occurred that PSO S’s recollection of events matched PSO R’s. PSO R confirmed that the hold placed on Patient #2 aligned with the specialized training all PSOs receive through the tactical range masters training program. PSO R reported at no point were other staff members trained to replicate the same type of hold used on Patient #2. PSO R reiterated that COU staff should follow the hold and restraint training and policies of the COU department. 7. During an interview on 09/23/2024 2:30 AM, COU RN P recalled it was confusing why the COU did not need an order to place a patient in a hold against their will to restrain or limit them from moving if using the Handle with Care techniques. COU RN P recalled in a normal mental health unit and order would be needed, and the provider would need to do a face to face with the patient. COU RN P recalled Patient #2 did become agitated, but COU RN P was unable to recall a time Patient #2 had to be held or restrained. COU RN P reported Patient #2 did not hit hard, and staff could have distanced themselves from Patient #2 as an intervention.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(2) Restraint or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient, a staff member, or others from harm. This Standard is not met as evidenced by: 51283 Based on medical record review, policy review, and staff interview, the hospital’s administrative staff failed to ensure staff utilized the least restrictive restraint interventions that may be reasonably determined to be effective in protecting patients, staff, and others for 1 of 10 sampled patients (Patient #2). Failure to employ minimally restrictive interventions -when actionable-placed patients at risk for acute stress and distress that may have been otherwise preventable. Findings include: 1. Review of the policy number 14.49.17 “Restraints/Restraints Management,” Last Reviewed 10/2023, revealed in part: a. “PURPOSE: To provide the safe, appropriate and clinically justified use of restraint/restraints. To educate colleagues and medical staff ... on the philosophy that every patient has a right to be free from restraint/restraints. (The hospital) leadership supports a culture in which restraint/restraints and/or is only used in situations that promote medical healing or utilized in situations of imminent danger to patients, colleagues, self, or others when less restrictive interventions have been attempted ...” b. “Restraint/restraints: Any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. This includes any drug or medication when it is used as a restriction to manage the patient ’ s behavior or restrict the patient ’ s freedom of movement and is not a standard treatment or dosage for the patient ’ s condition...” c. “ ...Violent Behavioral Restraint/restraints: The restriction of patient movement for the management of violent self-behavior that jeopardizes the immediate physical safety of the patient, colleagues or others ...” d. “Restraint/restraints may only be used: To ensure the immediate safety of the patient and/or others and not as a means of coercion, discipline, convenience or retaliation by staff members; when less restrictive measures have been identified, attempted and found to be ineffective in protecting the patient and/or others from imminent harm ...” e. “ ...The use of restraint/restraints for the management of patient behavior is not considered a routine part of care and requires written modification to the individual’s plan of care ...” f. “ ...The use of restraint/restraints is used in accordance with a [Licensed Practitioners] (LP) order for ensuring clinical justification of restraint/restraints use for protecting the patient’s rights, dignity and well-being ...” g. “ ...A registered nurse (RN) may initiate restraint/restraints in advance of an LP ’ s order if self-harm, and/or danger to others is imminent ...” h. “ ... Orders: Initial Order; obtain order within 1 hour of restraint/restraints or initiation; must include type of restraint/restraints age specific time limit, and reason for use; and must be seen face-to-face by LP within 1 hour. The attending provider must be notified as soon as possible if they did not order the restraint/restraints ...” 2. Review of the “Patient Observer Education,” Last Revised 8/2022, revealed in part: a. “Restraint Alternatives and Safe Restraint Use ... Modifications to the environment: limit physical access to life support devices, reduce sensory stimulation, improve lighting, obtain specialized low bed, use bed exit/chair alarm, use room/unit alarm systems (if available), clear clutter, keep personal items within reach, cluster cares. Address psychological concerns: provide reorientation/reassurance, provide diversional activities, assess/treat anxiety or agitation (nurse only). Address physical needs: schedule repositioning, assist ambulation as appropriate, anticipate nutrition, hydration, elimination needs, assess and treat pain discomfort (nurse only). Optimize Communication: communication board, pen and paper, interpretation and translation services ...” b. “Agitated patients - Signs that a patient is becoming agitated: increased movement; pacing, leg tapping, restless; increased volume; voice is getting louder for no reason; forced speech; talking at you not to you; patient may seem more intimidating or scary. Agitated people do not typically deescalate without help, they will normally escalate from agitation to aggression.” c. “Tips for dealing with an agitated patient ... respect personal space and do not crowd them, allow verbalization of frustrations and feelings in a judgement free zone, encourage silence - avoid chit chat, decrease stimulate ..., use short sentences with clear commands. Do not engage in unhealthy communication, if the patient is inappropriate, confrontational or argumentative you may choose to not engage and use therapeutic silence.” 3. Review of the “Handle with Care Behavior Management System,” Last Reviewed 2012, revealed in part: a. “Restraint Alternatives and Safe Restraint Use ... Modifications to the environment: limit physical access to life support devices, reduce sensory stimulation, improve lighting, obtain specialized low bed, use bed exit/chair alarm, use room/unit alarm systems (if available), clear clutter, keep personal items within reach, cluster cares. Address psychological concerns: provide reorientation/reassurance, provide diversional activities, assess/treat anxiety or agitation (nurse only). Address physical needs: schedule repositioning, assist ambulation as appropriate, anticipate nutrition, hydration, elimination needs, assess and treat pain discomfort (nurse only). Optimize Communication: communication board, pen and paper, interpretation and translation services ...” b. “Agitated patients - Signs that a patient is becoming agitated: increased movement; pacing, leg tapping, restless; increased volume; voice is getting louder for no reason; forced speech; talking at you not to you; patient may seem more intimidating or scary. Agitated people do not typically deescalate without help, they will normally escalate from agitation to aggression.” c. “Tips for dealing with an agitated patient ... respect personal space and do not crowd them, allow verbalization of frustrations and feelings in a judgment free zone, encourage silence - avoid chit chat, decrease stimulation ..., use short sentences with clear commands. Do not engage in unhealthy communication, if the patient is inappropriate, confrontational or argumentative you may choose to not engage and use therapeutic silence.” 4. During an interview on 09/23/2024 at 1:00 PM, Tech A confirmed COU RN Supervisor received notification on 08/19/2024 at 5:15 AM regarding the text messages and verbal conversation between Tech A and Tech B, which took place on 08/18/2024 at approximately 3:00 PM and 7:00 PM. 3. The survey team reviewed the hospitals internal investigation document on 09/23/2024 of text message screenshots obtained during the hospital investigation confirmed that Tech B admitted to smacking Patient #2 in the mouth. Tech B also admitted in text messages to holding Patient #2’s hands down to the counter and pinning her in bed. 4. During an interview on 09/24/2024 at 11:00 AM, Tech D reported that the Handle with Care training included verbal de-escalation techniques and methods to hold a patient to prevent further injury to self or others. Tech D confirmed the training did not permit restraints that tie down a person’s arms. Tech D confirmed Tech B slapped Patient #2 in the face with an open hand during an episode when Patient #2 spit at Tech B. Tech D reported standing next to Patient #2 during this alleged abuse, while Tech B stood on the opposite side of the nursing station desk when the slap occurred. Tech D confirmed that no verbal attempt was made to intervene. Tech D indicated that the appropriate intervention should have involved wearing a face shield and maintaining distance from Patient #2. Tech D stepped back when Patient #2 attempted to punch at the nursing station. Patient #2 was taken back to the bedroom to calm down and held down in bed twice for about five minutes each time. Patient #2 was restrained by the arms and shoulders. Tech D reported using a trained hold technique. Patient #2 could still move legs while being held down. Both Tech B and Tech D performed the holds on Patient #2. Patient #2 was “let up” and then held down again for another five minutes to prevent hitting staff until COU RN E arrived. COU RN E instructed Tech B and Tech D to release Patient #2. Tech D recalled that COU RN E witnessed Patient #2 being held down but would often disappear from the unit during the shift. During the 08/18/2024 shift, Patient #2 attempted to bite Tech B, prompting Tech B to tug on Patient #2’s hair as an intervention to stop this behavior. Tech D recalled that Patient #2 sat beside Tech D on the bench while Tech B stood at a distance during this incident. Patient #2 did not come into contact with Tech B’s skin nor attempt to bite Tech D whom sat next to Patient #2. Tech D described the shift as difficult due to Patient #2’s aggression and other personal issues. 5. During an interview on 09/25/2024 at 3:00 PM, Tech B recalled completing training on restraints with the Handle with Care program. Tech B recalled the weekend shifts from 7:00 AM to 7:00 PM on 08/17/2024 and 08/18/2024 were challenging. On 08/17/2024, Tech B placed a call to the local police department and the hospital’s public safety officers. Tech B reported this call for assistance arose from the unsafe situation on the unit, with Patient #2’s aggression being unmanageable. Tech B felt unable to care for other patients or ensure their safety due to Patient #2’s outbursts. Tech B reported on 08/17/2024 COU RN HH unit could not log into the computer or the Pyxis (medication) machine to obtain medications for Patient #2 or other patients. Tech B recalled IT (Information Technology) and pharmacy were contacted to assist COU RN HH. Tech B attempted to reach COU RN Supervisor (Supervisor for 4 W, COU) on the phone but did not receive a return call. Tech B reported calling in efforts to seek guidance and instruction from COU RN Supervisor . Tech B confirmed being present in the room with PSO (Public Safety Officer) S and PSO R. Tech reported observing the techniques employed by the public service officers. Tech B recalled PSO R asked about the plan, but no plan of action or care could be provided. Tech B reported Patient #2 calmed down after taking medication. On 08/17/2024, Tech B recalled Patient #2 was placed in a hold utilizing the same technique observed earlier that morning. Tech B reported using the same hold observed from PSO S and PSO R earlier that morning after obtaining permission from COU RN HH to use the same technique. Tech B requested clarification about the difference between the hold used by PSOs and restraining Patient #2. Tech B recalled COU RN HH stated that the distinction between soft restraints and the hold used was merely semantic. Tech B reported COU RN HH advised that since Patient #2 was not being tied down and was not being harmed, using the hold observed by the PSO was permissible. Tech B recalled Patient #2 was held down by shoulders, arms, legs, and hips. Tech B reported using a hold on Patient #2 that was not in the COU training or policy. Tech B reported using this same technique for Patient #2 on 08/17/2024 and 08/18/2024. Conversations occurred with Patient #2 while in the hold, with Patient #2 squirming when hands rested on the hip, prompting reminders not to get up. Tech B reported using a stern tone to advise Patient #2 not to hit others. On 08/18/2024, Tech D was assigned to serve as the one-on-one staff for Patient #2, who remained very agitated throughout the 7:00 AM to 7:00 PM shift. Tech B was assigned as the intake staff member on 08/18/2024. Tech B felt that Tech D was losing patience with Patient #2, who needed to leave the unit for about 20 minutes to take a break from the situation. During that time, one-on-one care was provided by Tech B until Tech D returned. Tech B reported COU RN E was aware of Patient #2’s agitated states and altercations with staff. Tech B recalled COU RN E witnessed Patient #2 attempting to break the computer and phone at the nursing station. Tech B explained spitting incidents occurred, with spit landing in Tech B’s eye, while distance was maintained by moving around to the other side of the nursing station. Tech B reported Patient #2 hands were held and Tech B’s fingers were placed over Patient #2’s mouth. Tech B reported telling Patient #2 sternly to stop. Time was spent in the lobby with Patient #2, assisting with hair care by Tech B. Tech B recalled COU RN E was aware of Patient #2’s aggression and did not assist either Tech B or Tech D. Tech B reported being punched by Patient #2 and was advised by COU RN E to complete a variance report. Tech B explained Patient #2 was placed in a hold, a restraint order was not needed since the Handle with Care program was used. Tech B recalled during the 08/18/2024 shift, an attempt was made to brush and braid Patient #2 hair. Tech B denied tugging on Patient #2 during that time. Tech B recalled Patient #2 having tangled and knotted hair. Tech B recalled the policies on the COU were not well understood or clear. 6. During an interview on 09/26/2024 at 12:25 PM with PSO R, confirmation occurred that PSO S’s recollection of events matched PSO R’s. PSO R confirmed that the hold placed on Patient #2 aligned with the specialized training all PSOs receive through the tactical range masters training program. PSO R reported at no point were other staff members trained to replicate the same type of hold used on Patient #2. PSO R reiterated that COU staff should follow the hold and restraint training and policies of the COU department.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(ii) [The use of restraint or seclusion must be--] (ii) implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy in accordance with State law. This Standard is not met as evidenced by: 51283 Based on medical record review, policy review, and staff interviews, the hospital’s administrative staff failed to ensure staff safely and appropriately implemented restraint techniques in accordance with applicable hospital policies for 1 of 10 sampled patients (Patient #2). Failure to implement physical restraints in a manner that was safe and appropriate placed patients at risk for serious emotional or physical trauma, including acute distress, delirium, contractures, fractures, pressure ulcers, edema, airway obstruction, and death. Findings include: 1. Review of the policy number 14.49.17 “Restraints/Restraints Management,” Last Reviewed 10/2023, revealed in part: a. “PURPOSE: To provide the safe, appropriate and clinically justified use of restraint/restraints. To educate colleagues and medical staff ... on the philosophy that every patient has a right to be free from restraint/restraints. (The hospital) leadership supports a culture in which restraint/restraints and/or is only used in situations that promote medical healing or utilized in situations of imminent danger to patients, colleagues, self, or others when less restrictive interventions have been attempted ...” b. “Restraint/restraints: Any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. This includes any drug or medication when it is used as a restriction to manage the patient ’ s behavior or restrict the patient ’ s freedom of movement and is not a standard treatment or dosage for the patient ’ s condition...” c. “ ...Violent Behavioral Restraint/restraints: The restriction of patient movement for the management of violent self-behavior that jeopardizes the immediate physical safety of the patient, colleagues or others ...” d. “Restraint/restraints may only be used: To ensure the immediate safety of the patient and/or others and not as a means of coercion, discipline, convenience or retaliation by staff members; when less restrictive measures have been identified, attempted and found to be ineffective in protecting the patient and/or others from imminent harm ...” e. “ ...The use of restraint/restraints for the management of patient behavior is not considered a routine part of care and requires written modification to the individual’s plan of care ...” f. “ ...The use of restraint/restraints is used in accordance with a [Licensed Practitioners] (LP) order for ensuring clinical justification of restraint/restraints use for protecting the patient’s rights, dignity and well-being ...” g. “ ...A registered nurse (RN) may initiate restraint/restraints in advance of an LP ’ s order if self-harm, and/or danger to others is imminent ...” h. “ ... Orders: Initial Order; obtain order within 1 hour of restraint/restraints or initiation; must include type of restraint/restraints age specific time limit, and reason for use; and must be seen face-to-face by LP within 1 hour. The attending provider must be notified as soon as possible if they did not order the restraint/restraints ...” 2. Review of the “Patient Observer Education,” Last Revised 8/2022, revealed in part: a. “Restraint Alternatives and Safe Restraint Use ... Modifications to the environment: limit physical access to life support devices, reduce sensory stimulation, improve lighting, obtain specialized low bed, use bed exit/chair alarm, use room/unit alarm systems (if available), clear clutter, keep personal items within reach, cluster cares. Address psychological concerns: provide reorientation/reassurance, provide diversional activities, assess/treat anxiety or agitation (nurse only). Address physical needs: schedule repositioning, assist ambulation as appropriate, anticipate nutrition, hydration, elimination needs, assess and treat pain discomfort (nurse only). Optimize Communication: communication board, pen and paper, interpretation and translation services ...” b. “Agitated patients - Signs that a patient is becoming agitated: increased movement; pacing, leg tapping, restless; increased volume; voice is getting louder for no reason; forced speech; talking at you not to you; patient may seem more intimidating or scary. Agitated people do not typically deescalate without help, they will normally escalate from agitation to aggression.” c. “Tips for dealing with an agitated patient ... respect personal space and do not crowd them, allow verbalization of frustrations and feelings in a judgment free zone, encourage silence - avoid chit chat, decrease stimulation ..., use short sentences with clear commands. Do not engage in unhealthy communication, if the patient is inappropriate, confrontational or argumentative you may choose to not engage and use therapeutic silence.” 3. Review of the “Handle with Care Behavior Management System,” Last Reviewed 2012, revealed in part: a. “Restraint Alternatives and Safe Restraint Use ... Modifications to the environment: limit physical access to life support devices, reduce sensory stimulation, improve lighting, obtain specialized low bed, use bed exit/chair alarm, use room/unit alarm systems (if available), clear clutter, keep personal items within reach, cluster cares. Address psychological concerns: provide reorientation/reassurance, provide diversional activities, assess/treat anxiety or agitation (nurse only). Address physical needs: schedule repositioning, assist ambulation as appropriate, anticipate nutrition, hydration, elimination needs, assess and treat pain discomfort (nurse only). Optimize Communication: communication board, pen and paper, interpretation and translation services ...” b. “Agitated patients - Signs that a patient is becoming agitated: increased movement; pacing, leg tapping, restless; increased volume; voice is getting louder for no reason; forced speech; talking at you not to you; patient may seem more intimidating or scary. Agitated people do not typically deescalate without help, they will normally escalate from agitation to aggression.” c. “Tips for dealing with an agitated patient ... respect personal space and do not crowd them, allow verbalization of frustrations and feelings in a judgment free zone, encourage silence - avoid chit chat, decrease stimulation ..., use short sentences with clear commands. Do not engage in unhealthy communication, if the patient is inappropriate, confrontational or argumentative you may choose to not engage and use therapeutic silence.” 4. During an interview on 09/23/2024 at 1:00 PM, Tech A confirmed COU RN Supervisor received notification on 08/19/2024 at 5:15 AM regarding the text messages and verbal conversation between Tech A and Tech B, which took place on 08/18/2024 at approximately 3:00 PM and 7:00 PM. 5. The survey team reviewed the hospitals internal investigation document on 09/23/2024 of text message screenshots obtained during the hospital investigation confirmed that Tech B admitted to smacking Patient #2 in the mouth. Tech B also admitted in text messages to holding Patient #2’s hands down to the counter and pinning her in bed. 6. During an interview on 09/24/2024 at 11:00 AM, Tech D reported that the Handle with Care training included verbal de-escalation techniques and methods to hold a patient to prevent further injury to self or others. Tech D confirmed the training did not permit restraints that tie down a person’s arms. Tech D confirmed Tech B slapped Patient #2 in the face with an open hand during an episode when Patient #2 spit at Tech B. Tech D reported standing next to Patient #2 during this alleged abuse, while Tech B stood on the opposite side of the nursing station desk when the slap occurred. Tech D confirmed that no verbal attempt was made to intervene. Tech D indicated that the appropriate intervention should have involved wearing a face shield and maintaining distance from Patient #2. Tech D stepped back when Patient #2 attempted to punch at the nursing station. Patient #2 was taken back to the bedroom to calm down and held down in bed twice for about five minutes each time. Patient #2 was restrained by the arms and shoulders. Tech D reported using a trained hold technique. Patient #2 could still move legs while being held down. Both Tech B and Tech D performed the holds on Patient #2. Patient #2 was “let up” and then held down again for another five minutes to prevent hitting staff until COU RN E arrived. COU RN E instructed Tech B and Tech D to release Patient #2. Tech D recalled that COU RN E witnessed Patient #2 being held down but would often disappear from the unit during the shift. During the 08/18/2024 shift, Patient #2 attempted to bite Tech B, prompting Tech B to tug on Patient #2’s hair as an intervention to stop this behavior. Tech D recalled that Patient #2 sat beside Tech D on the bench while Tech B stood at a distance during this incident. Patient #2 did not come into contact with Tech B’s skin nor attempt to bite Tech D whom sat next to Patient #2. Tech D described the shift as difficult due to Patient #2’s aggression and other personal issues. 7. During an interview on 09/25/2024 at 3:00 PM, Tech B recalled completing training on restraints with the Handle with Care program. Tech B recalled the weekend shifts from 7:00 AM to 7:00 PM on 08/17/2024 and 08/18/2024 were challenging. On 08/17/2024, Tech B placed a call to the local police department and the hospital’s public safety officers. Tech B reported this call for assistance arose from the unsafe situation on the unit, with Patient #2’s aggression being unmanageable. Tech B felt unable to care for other patients or ensure their safety due to Patient #2’s outbursts. Tech B reported on 08/17/2024 COU RN HH unit could not log into the computer or the Pyxis (medication) machine to obtain medications for Patient #2 or other patients. Tech B recalled IT (Information Technology) and pharmacy were contacted to assist COU RN HH. Tech B attempted to reach COU RN Supervisor (Supervisor for 4 W, COU) on the phone but did not receive a return call. Tech B reported calling in efforts to seek guidance and instruction from COU RN Supervisor . Tech B confirmed being present in the room with PSO (Public Safety Officer) S and PSO R. Tech reported observing the techniques employed by the public service officers. Tech B recalled PSO R asked about the plan, but no plan of action or care could be provided. Tech B reported Patient #2 calmed down after taking medication. On 08/17/2024, Tech B recalled Patient #2 was placed in a hold utilizing the same technique observed earlier that morning. Tech B reported using the same hold observed from PSO S and PSO R earlier that morning after obtaining permission from COU RN HH to use the same technique. Tech B requested clarification about the difference between the hold used by PSOs and restraining Patient #2. Tech B recalled COU RN HH stated that the distinction between soft restraints and the hold used was merely semantic. Tech B reported COU RN HH advised that since Patient #2 was not being tied down and was not being harmed, using the hold observed by the PSO was permissible. Tech B recalled Patient #2 was held down by shoulders, arms, legs, and hips. Tech B reported using a hold on Patient #2 that was not in the COU training or policy. Tech B reported using this same technique for Patient #2 on 08/17/2024 and 08/18/2024. Conversations occurred with Patient #2 while in the hold, with Patient #2 squirming when hands rested on the hip, prompting reminders not to get up. Tech B reported using a stern tone to advise Patient #2 not to hit others. On 08/18/2024, Tech D was assigned to serve as the one-on-one staff for Patient #2, who remained very agitated throughout the 7:00 AM to 7:00 PM shift. Tech B was assigned as the intake staff member on 08/18/2024. Tech B felt that Tech D was losing patience with Patient #2, who needed to leave the unit for about 20 minutes to take a break from the situation. During that time, one-on-one care was provided by Tech B until Tech D returned. Tech B reported COU RN E was aware of Patient #2’s agitated states and altercations with staff. Tech B recalled COU RN E witnessed Patient #2 attempting to break the computer and phone at the nursing station. Tech B explained spitting incidents occurred, with spit landing in Tech B’s eye, while distance was maintained by moving around to the other side of the nursing station. Tech B reported Patient #2 hands were held and Tech B’s fingers were placed over Patient #2’s mouth. Tech B reported telling Patient #2 sternly to stop. Time was spent in the lobby with Patient #2, assisting with hair care by Tech B. Tech B recalled COU RN E was aware of Patient #2’s aggression and did not assist either Tech B or Tech D. Tech B reported being punched by Patient #2 and was advised by COU RN E to complete a variance report. Tech B explained Patient #2 was placed in a hold, a restraint order was not needed since the Handle with Care program was used. Tech B recalled during the 08/18/2024 shift, an attempt was made to brush and braid Patient #2 hair. Tech B denied tugging on Patient #2 during that time. Tech B recalled Patient #2 having tangled and knotted hair. Tech B recalled the policies on the COU were not well understood or clear. 8. During an interview on 09/26/2024 at 12:25 PM with PSO R, confirmation occurred that PSO S’s recollection of events matched PSO R’s. PSO R confirmed that the hold placed on Patient #2 aligned with the specialized training all PSOs receive through the tactical range masters training program. PSO R reported at no point were other staff members trained to replicate the same type of hold used on Patient #2. PSO R reiterated that COU staff should follow the hold and restraint training and policies of the COU department. 9. During an interview with the Public Safety Officer (PSO) S on 09/26/2024 at 12:12 PM. PSO S recalled needing to assist in a de-escalation call on 08/17/2024 in the COU. PSO S reported Patient #2 generally responded well to verbal de-escalation techniques when PSOs were called to the unit. On 08/17/2024 at 9:41 AM, dispatch received a call reporting a disruptive patient. Two local police arrived on the scene along with two public safety officers. Dispatch notes indicated the need for medication and standby for disruptive patients in the COU. PSO S reported having to ask the staff about the situation, what assistance was needed, and what the plan was going forward. PSO S recalled unit staff appeared disorganized and required frequent prompting for a plan. PSO S recalls frequent calls to the COU unit for Patient #2, who often expressed a desire to go home. PSO S recalled COU staff advised the public safety staff to assist Patient #2 to bed to calm down. PSO S reported being unable to recall the names of staff working that day. PSO S recalled Patient #2 resisted sitting in a wheelchair and did not want to remain in bed. PSO S assisted Patient #2 in adjusting position in bed to prevent falling. Patient #2 exhibited agitation, spitting, and hitting. PSO S reported PSO R was struck by Patient #2. While in the room with Patient #2, PSO S had to repeatedly ask COU staff about the plan and whether medication would be administered or if a doctor would come to assess Patient #2. PSO S recalled clear answers were not provided, and COU staff were observed watching the public safety officers. PSO S voiced Patient #2 was held in bed at the direction of COU staff on duty. PSO S recalled using a hold that involved placing a hand on Patient #2’s shoulder and another on the arm to prevent flailing around and preventing Patient #2 from hurting self and others. PSO S reported the hold used, was done from the specialized training all PSOs receive and adhered to in accordance with the PSO department’s policy. PSO S recalled this intervention lasted approximately 15 minutes until the nurse on duty was able to administer medication to Patient #2.”