HospitalInspections.org

Based on policy review, staff interview and personnel record review the facility failed to ensure patients are free of abuse when:
1) Patients were physically held by staff in one of one (#21) patients; and,
2) One of one (#21) patients physically assaulted other patients on the psychiatric unit.

The facility census was 46.

Findings included:

1. Record review of the facility policy titled "Patient rights" policy # 0232, Board of Trustees approval date, 09/26/11, revised date 08/11, gave the following direction:
Policy: The facility will preserve the basic rights of human beings for independent expression, decision, action, concern for personal dignity, and concern for human relationships, most especially necessary during illness to assist in survival and recovery.
Purpose: It is a prime responsibility for employees to endeavor to assure that patient rights are preserved.
Patient Rights - Respect and Dignity section: The patient has the right to considerate, respectful care at all times and under all circumstances, with recognition of his personal dignity and will receive this type of care while a patient at the facility.
Patient Rights - Personal Safety section: The patient has the right to expect reasonable safety insofar as the hospital practices and environment are concerned and this will be provided to the highest degree possible by safe care, occurrence report follow-up, in-services and Performance Improvement.

Review of facility policy titled, "Patient Abuse" reference # 0230, revised, 04/08 gave the following direction:
Purpose: The patient will be free from any physical abuse or neglect while in our facility. Our first line of action is always to protect the patient. All personnel must promptly report any incident or suspected incident of patient abuse, including injuries of an unknown source to the Charge Nurse, House Supervisor, and/or Social Worker.
-Patients have the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. Our facility will not condone patient abuse by anyone, including staff members, patients, consultants, volunteers, staff of other agencies serving the family, family members, legal guardians, spouse, friends or other individuals. Any alleged violations involving mistreatment, neglect or abuse, including injuries of unknown source and misappropriation of resident property, must be reported to the Charge Nurse, house Supervisor and/or Social Worker.
-Abuse Reporting Guide:
1. All personnel must immediately report any occurrence or suspected occurrence of patient abuse/neglect which includes any injury of an unknown origin to the Charge Nurse and/or Social Worker.
2. When a suspected or alleged case of abuse, neglect or any form of mistreatment is reported the social worker or other staff will assure the patient's safety and then notify the following personnel and agencies of the incident:
A. Department of Health and Senior Services Hotline 1-800-392-0210; and
B. Risk Manager - ext. 3042.
3. All personnel, residents, visitors and others are encouraged to report incidents of patient abuse/neglect or suspected incidents of abuse/neglect. Such reports may be made without fear of retaliation from the facility or its staff.
-The patient will be assured protection throughout the evaluation investigation, from the time commencing from the suspected report forward to prevent any abuse or concern.
-Reporting/Response: Each reportable incident must also be reported to the appropriate state agency by telephone within 24 hours. The facility shall submit any information requested to the Division of Aging and Department of Health to report abuse, neglect and/or an unusual occurrence.

2. During an interview on 05/22/12, at 11:00 AM, Staff E, Program Director Senior Mental Health, stated that there have been no complaints of staff abuse against patients for the year 2012. Staff E, further stated about two years ago there were two female nurse assistants that were fired for patient abuse.

During an interview on 05/22/12, at 11:15 AM, Staff E, Program Director Senior Mental Health, stated that the facility does not use restraints of any kind in the behavioral health unit. This included no restraints by physical hold where a staff member would hold the patient with their hands.

3. During an interview on 05/22/12 at 3:35 PM, Staff O, Coordinator of Risk Management, stated that one or two years ago a couple of staff were discharged for patient abuse, but she has not heard of cases of patient abuse since and has not investigated anything related to abuse since.

4. During an interview on 05/23/12 at 8:50 AM, Staff L, Psychiatric Certified Nurse's Aide (CNA) stated that:
-He worked night shift and has been working for the facility for two years come 08/2012;
-The patients fight us and patients are restrained by grabbing an arm of the patient until the patient calms down. This happens at least once a night. It would be an odd night if this didn't happen;
- He grabbed and held Patient #21 in a "bear hug" by wrapping his arms around the patient and holding the patient's arms down;
-Patient holds usually last five to ten minutes;
-He has done 45 minute patient holds a couple of dozen times over the term of his employment;
-He held Patient #23 with a physical hold for 45 minutes last week;
-He stated the staff was not allowed to use restraints, meaning wrist or leg restraints, but does grab patients and holds them with a physical hold.

5. During an interview on 05/23/12 at 5:25 PM, Staff G, Psychiatric CNA, stated that he worked full time on night shift and recalled Patient #24 being physically held for 15-20 minutes.

6. Review of the personnel record for Staff L, Psychiatric CNA, showed an employee disciplinary action notice dated 06/03/11 which was noted as a written warning with no disciplinary action.
-Attached to the written warning was a document dated 06/02/11, 5 PM, Patient #25 stated that she was upset from the happenings over night shift with staff. Patient reported that she was made to lie in her bed and not allowed to get up. She verbalized she didn't like sleeping in beds and preferred recliners. She screamed because she didn't like now she was being treated. She had a call bell and it was taken away from her. She reported that she needed to go to the bathroom. She was told that she had a diaper on and therefore she didn't need to get up and she needed to stay in bed. The patient ended up soiling her diaper and reports she sat in it for three hours and staff were angry at her for doing so. The patient is now afraid to tell staff that she needs something or she has to use the restroom. The patient reported staff members were on cell phones during work. The patient threatened to tell on them, but was told it didn't matter. The patient stated she was made to lie in bed one hour longer because she screamed. She identified the staff as a "big guy" and a girl both CNA's.
-The written disciplinary action notice included the writer spoke with Patient #25 and Patient #25 specifically name Staff L, Psychiatric CNA.
-The corrective action recommended: Immediate change in behavior/actions toward patients that reflect our policy of speaking in a calm friendly tome. Not denying requests from patients such as getting up at night if they are felling anxious or upset. Allowing them to sleep in Geri-Chairs (recliners) if that is they are use to. Allowing drinks of water at night and by their bedside. Not removing the patient's ability to get assistance when need at night and if the patient is disruptive to the milieu then take them to the dayroom until comfortable and call the physician for assistance. If a patient becomes so disruptive you need a break have your charge nurse take turns as well as other techs as per policy. The report is signed by Staff L, Psychiatric CNA and Staff E, Program Director Senior Mental Health, on 06/03/11.

7. During an interview on 05/23/12 at 2:00 PM, Staff E, Program Director Senior Mental Health, stated that:
-It is not acceptable for facility staff to do physical holds on patients;
-Staff doing "Bear-hug" holds on patients is not acceptable;
-There is not a policy on physical holds because we are not to do physical holds at this facility;
-There will not be any physician orders for physical holds in any patient clinical records because physical holds are not to be done at this facility;
-The patient abuse event involving Staff L, Psychiatric CNA, was not reported to the survey team because Staff E stated she had forgotten about it;
-She confirmed the facility failed to notify the state agency of the patient abuse events that occurred with the two CNA's prior to the event involving Staff L and also failed to report the abuse event that did involve Staff L; and
-She confirmed Staff L was not removed from patient care at any point and Staff L did not receive additional supervision on night shift after the incident of patient abuse was identified.

8. During an interview on 05/22/12 at 8:05 AM with Patient #15, he stated that he is afraid of Patient #21. He stated that he has seen Patient #21 "go off" (looses control and hits) without any warning and he hits other patients. He stated he saw Patient #21 hit a lady patient in the back and hit another male patient. He stated if he see's Patient #21 coming he gets out of the way. He stated Patient #21 goes off quick.

9. Review of the clinical record for Patient #21 showed the following in the psychiatric evaluation conducted by the patient's psychiatrist on 05/02/12 at 6:01 PM:
-The patient was brought into the hospital because of profound disabling hallucinations (seeing things that are not there), agitative, aggressive, combative behavior. According to the family, he has become increasingly anxious, paranoid (suspicious and fearful of others) and guarded, actively hallucinating, not sleeping at all most of the night, resistive, and uncooperative with his care. The wife was concerned for the patient's safety and also her safety. The patient has a diagnosis of dementia (debilitation disease of the brain) with delusions (firmly fixed false beliefs). Affectively, he is suspicious and guarded, hypervigilant. There is evidence of distressing paranoia and also experiencing visual hallucinations. Judgment and insight are poor at this time.
-Continued review of the medical record showed:
Physician progress notes 05/17/12 showed the patient was experiencing periods of increasing, agitation, combative, aggressive and threatening behavior. Still gets physically threatening, actively hallucinating, still wandering around, difficult to redirect, and difficult to sit still.
Nursing note on 05/06/12, 7:00 AM to 7:00 PM showed Patient #21 threatens staff, "I will kill you," and on impulse starts running toward the window stating, "I can bust it all down " Called physician with no new orders given. Difficult to redirect patient.
Nursing note on 05/07/12, 7:00 AM to 7:00 PM, showed Patient #21 banging on picture window this morning and said, "I' m going to kill somebody " and then said, "I'll kill myself." Patient #21 has been very intrusive with staff gets close to staff and get's his face to close to theirs. This AM also yelled at CNA,"I'm going to kill you" as he walked through the dining room. Banged his head into the picture window and then started hitting the walls. Physician ordered Depakote (a drug used to treat seizure disorders, anxiety and other disorders) 500 mg (milligram - a unit of measure) at 4:00 PM.
Nursing note on 05/09/12, 7:00 AM to 7:00 PM, showed Patient #21 running in the halls and punching at staff. Kicked at glass window in the hall. Close contact with others.
Nursing note on 05/09/12, 7:00 PM to 7:00 AM, showed Patient #21 as angry, agitated and threatening. Patient is yelling and taken to his room.
Nursing note on o5/12/12, 7:00 AM to 7:00 PM, showed Patient #21 pacing up and down the halls and in and out of other patient rooms continuously.
-The record review for Patient #21 showed the patient was on every 15 minute observation for assaultive behavior, but was not placed on a continual 1:1 (one staff member to watch one patient) to protect other patients from assault.