South Mississippi State Hospital

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 46164 RE: COMPLAINT INVESTIGATIONS #MS00029778 & MS00029779 Based on video surveillance review, staff interviews, facility policy and procedure review the facility staff failed to recognize abuse by the inappropriate use of a physical restraint hold in the form of a throat chokehold or intervene on behalf of a patient to ensure patient safety, which resulted in abuse, placing the patient and other patients in the facility in an unsafe environment as evidenced by the video surveillance footage for one (1) of 43 patients in the facility: Patient #1 Findings Include: Review of the video surveillance footage of the C Unit during the B shift (3:00 p.m. to 11:30 p.m.) on 09/24/2025 at 01:35 p.m. with the Director of Risk Management (DRM) revealed: C Unit -B shift-View front lobby 08/27/2025: 04:45:47 p.m.-Support Care Professional Supervisor (SCPS #1) grabs Patient #1 with both hands around her throat and neck and forcibly pushes Patient #1 to the floor directly in front of the nurse’s station; SCPS #1 hits head on the nurse’s station counter as Patient #1 is going to the floor. An interview on 09/24/2025 at 2:59 p.m. with the Fiscal Services Director (FSD), confirms he was the Administrator in Charge on 08/25, 08/26, and 08/27/2025 when the Hospital Director (HD) was not present in the facility. The FSD confirms reviewing the video surveillance with the DRM the afternoon of 08/26/2025 of an incident involving SCPS #1 applying an unauthorized physical hold on a Patient in the Male Unit on 08/25/2025. The FSD stated, he “ ...was unable to determine if Patient #1 (from the incident on 08/25/2025) was being choked or in a headlock by SCPS #1 ...”. SCPS #1 was not placed on Administrative Leave after he reviewed the video. The FSD also confirmed the Hospital Director or Administrator on Call were the only people in the facility who could place an employee on administrative leave. He confirmed SCPS #1 was allowed to work the scheduled shift of 3:00 p.m. to 11:30 p.m. on 08/26/2025 and 08/27/2025. Review of the facility’s policy, POL 182-02, Suspicion of Abuse, Neglect or Exploitation and Patient Injuries of an Unknown Case Occurring After Admission, dated January 2020, “ ...The purpose of this policy is to outline the procedures for reporting and investigating situations in accordance with the State of Mississippi Vulnerable Adults Act, where there is reason to suspect a patient ...has been the victim of abuse ...It is the policy ...that all situations of suspected abuse ...be reported and investigated in accordance with the following ...procedures ... Employees will immediately make an oral report to their supervisor and the Risk Management/Security Department when they: 1. Witness or discover situations in which they suspect ...abuse, neglect, or exploitation ...Employees will ...complete ...Patient Accident/Incident Form ...forward it to the Risk Management/Security Department ...Employees suspected of abuse and/or neglect will be removed from all patient care duties and placed on administrative leave until the conclusion of the investigation ...The Risk Management Department ...and the Human Resources Department will conduct investigations of reports of situations where the patient is believed to be the victim of abuse ...The Risk Management ...Notification of other situations will be by written report at the end of the investigation ...The Director of Risk Management ...within the scope of his employment ...shall report suspected abuse ...to the Mississippi Department of Human Services and the Medicaid Fraud Control Unit of the Attorney General’s office within 24 hours ...A written report must be submitted within 72 hours to the same agencies ...”. Review of the facility’s policy, POL 160-04 Attachment A, Rights of Individuals Receiving Services ...applies to all patients and employees ...each individual receiving services ...will be protected and that he/she will receive care consistent with basic human dignity ...will apply to each individual receiving services ...page 11 ...be treated under the least restrictive conditions ...page 13 ...the right to a safe, sanitary, and humane physical environment ...the right to be protected from harm, abuse, and exploitation ...”. During the exit conference on 09/26/2025 at 12:00 p.m. with Behavioral Health Specialist (BHS), Performance Improvement Coordinator (PIC), Director of Operations (DO), Physician Assistant (PA), Chef Nurse (CN), Support Care Patient Supervisor (SCPS) #2, Fiscal Services Director (FSD), Staff Development Director (SDD), Registered Nurse (RN) Clinical Support Coordinator, Director of Risk Management (DRM), and Hospital Director (HD), survey findings were discussed, and no further documentation was submitted for review.”

“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: 46164 RE: COMPLAINT INVESTIGATIONS #MS00029778 & MS00029779 Based on video surveillance review, staff interviews, facility policy and procedure review; the facility staff failed to identify and correctly report an inappropriate physical restraint hold in the form of a throat chokehold position by a Support Care Professional Supervisor and the hospital leadership failed to ensure systems and processes were implemented to prevent patient abuse of a one (1) of 43 residents, Patient #1. Findings Include: Review of the video surveillance footage on 09/24/2025 at 1:35 p.m. with the Director of Risk Management (DRM) revealed: C Unit, B shift-View front lobby 08/27/2025: 04:45:47 p.m.-Support Care Professional Supervisor (SCPS #1) grabs Patient #1 with both hands around her throat and neck and forcibly pushes Patient #1 to the floor directly in front of the nurse’s station; SCPS #1 hits head on the nurse’s station counter as Patient #1 is going to the floor. During an interview on 09/24/2025 at 02:59 p.m. with the Fiscal Services Director (FSD), confirmed he was the Administrator in Charge on 08/25, 08/26, and 08/27/2025 when the Hospital Director (HD) was not present in the facility. The FSD confirmed reviewing video surveillance with the Director of Risk Management (DRM) on the afternoon of 08/26/2025 regarding an incident on 08/25/2025 involving SCPS #1. The FSD confirmed he was unable to determine if Patient #1 (from the incident on 08/25/2025) was being choked or in a headlock by SCPS #1, and SCPS #1 was not placed on Administrative Leave and continued to work regular scheduled hours, after he reviewed the video. The FSD confirmed he was the only person in the facility that could place an employee on Administrative Leave when designated as the Administer in Charge. He confirmed SCPS #1 was allowed to work the scheduled shift of 3:00 p.m. to 11:30 p.m. on 08/26/2025 and on 08/27/2025, the date of the next incident. Review of the facility’s policy, Section V-Policies Related to the People Receiving Services, date 01/01/2020, “ ...H. Abuse, Neglect or Exploitation of people receiving services ...Under no circumstances will an employee strike, shove, pinch ...neglect or otherwise subject any person receiving services to violent treatment ...Any employee witnessing or having suspicion of any mistreatment, violence ...physical abuse ...must report the incident immediately. If an immediate report is not possible, the employee must report the incident no later than the end of the shift. Failure to report the offense to proper authorities may result in disciplinary action ...abuse ...of people receiving services are very serious offenses and may result in immediate removal from the workplace and termination of employment. Further, such actions may lead to criminal prosecution to the fullest extent of the law ...To maintain an employee in a position caring for people receiving services under such circumstances could constitute negligence in regard to the agency’s duties to the people ...serves, the public or to the other ...employees ...”. During the exit conference on 09/26/2025 at 12:00 p.m. with Behavioral Health Specialist (BHS), Performance Improvement Coordinator (PIC), Director of Operations (DO), Physician Assistant (PA), Chef Nurse (CN), Support Care Patient Supervisor (SCPS) #2, Fiscal Services Director (FSD), Staff Development Director (SDD), Registered Nurse (RN) Clinical Support Coordinator, Director of Risk Management (DRM), and Hospital Director (HD), survey findings were discussed, and no further documentation was submitted for review.”

“QUALITY IMPROVEMENT ACTIVITIES CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3) (b) Program Data (2) [The hospital must use the data collected to - .....] (ii) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. This Standard is not met as evidenced by: 46164 RE: COMPLAINT # MS00029778 Based on staff interviews, review of the facilities documented retraining of staff, and the facility’s Corrective Action Plan, dated 09/23/2025, the facility failed to initiate an acceptable corrective action plan to address patient safety and quality of care prior to the initiation of the survey on 09/23/2025 related to the incident that occurred for one (1) of 43 patients in the facility, Patient #1 on 08/27/2025. Findings Include: During an interview with the Hospital Director (HD) on 09/23/2025 at 11:41 a.m., it was confirmed the facility has scheduled as part of the immediate corrective action plan regarding the incident on 08/25/2025 and 08/27/2025, a mandatory facility wide in-service scheduled for October 13 and October 14, 2025, by a representative from the Attorney General’s Office. It was further confirmed by HD, a facility wide Quality Assurance Performance Improvement (QAPI) activity relating to the incidents that occurred on 08/25/2025 and 08/27/2025 are not in place at this time. The HD confirmed some of the employees involved in the incident have received retraining. Review of the facility document, Attendance and Reporting Accountability Roster, “ ...Title: 08/27/2025 video footage ...Date: 09/10/2025 ...Time: 1545 (03:45 p.m.) ...Name: Registered Nurse (RN #2), Support Care Professional (SCP #2) and SCP #3 ...signature ...RN #2, SCP #2, and SCP #3 ...”. Review of the facility document presented on 09/26/2025 from the HD titled, Corrective Action Plan, was created by the designated leadership committee on the evening of 09/23/2025, after the initiation of the survey for the incident that occurred on 08/25/2025. During the exit conference on 09/26/2025 at 12:00 p.m. with Behavioral Health Specialist (BHS), Performance Improvement Coordinator (PIC), Director of Operations (DO), Physician Assistant (PA), Chef Nurse (CN), Support Care Patient Supervisor (SCPS) #2, Fiscal Services Director (FSD), Staff Development Director (SDD), Registered Nurse (RN) Clinical Support Coordinator, Director of Risk Management (DRM), and Hospital Director (HD), survey findings were discussed, and no further documentation was submitted for review.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 46164 RE: COMPLAINT # MS00029779 Based on staff interviews, review of the facilities documented retraining of staff, and the facility’s Corrective Action Plan, dated 09/23/2025, 29 days after the incident occurred, the facility’s Executive team failed to ensure an acceptable corrective action plan to address patient safety and quality of care was developed and implemented prior to the initiation of the survey on 09/23/2025 for a reported incident that occurred on 08/25/2025 for one (1) of four (4) days of survey. Findings Include: During an interview with the Director of Risk Management (DRM) on 09/23/2025 at 11:41 a.m., it was confirmed that the Registered Nurse Supervisor (RNS) was present at a different time and the Registered Nurse (RN #1) on duty was present for the retraining policies and video surveillance review but failed to sign an attendance form. No documented evidence of attendance. An interview with the Hospital Director (HD) on 09/23/2025 at 11:41 a.m., confirmed the facility scheduled as part of the immediate corrective action plan regarding the incident on 08/25/2025, a mandatory facility wide in-service on October 13 and October 14, 2025, presented by a representative from the Attorney General’s Office. The HD also confirmed SCPS #1 was placed on administrative leave on 08/28/2025 when the HD returned to the facility and video surveillance was reviewed. The HD confirmed an analysis and facility wide Quality Assurance Performance Improvement (QAPI) activity for the adverse event occurring on 08/25/2025 is not completed at this time. The HD confirmed some of the employees involved in the incident have received retraining. Review of the facility document, Attendance and Reporting Accountability Roster reveal employees who have had retraining “ ...Title: 08/25/2025 video footage ...Date: 09/11/2025 ...Time: 1545 (03:45 p.m.) ...Name: SCP #2 and SCP #3 ...signature ...SCP #2 and SCP #3 ...”. Review of the facility document presented on 09/26/2025 from the HD titled, Corrective Action Plan, was created by the designated leadership committee on the evening of 09/23/2025, after the initiation of this survey for an incident that occurred on 08/25/2025. During the exit conference on 09/26/2025 at 12:00 p.m. with Behavioral Health Specialist (BHS), Performance Improvement Coordinator (PIC), Director of Operations (DO), Physician’s Assistant (PA), Chief Nurse (CN), Support Care Professional Supervisor (SCPS) #2, Fisal Services Director (FSD), Staff Development (SD), Staff Development Director (SDD), Registered Nurse (RN) Clinical Support Coordinator, Director of Risk Management (DRM), and Hospital Director (HD), survey findings were discussed, and no further documentation was submitted for review.”