HospitalInspections.org

Based on interviews, record reviews, review of the facility's policies, review of the facility's risk management investigation, review of the facility's Crisis Prevention Intervention Manual (CPI), and review of the facility's video footage with the video review log, it was determined the facility failed to ensure one (1) of ten (10) sampled patients (Patient #1) was free from abuse. In addition, it was determined the facility failed to ensure staff immediately reported suspected and/or actual abuse when on two (2) different incidents a Mental Health Associate (MHA) thought excessive force was used during a physical restraint hold and failed to intervene and report the incident to their supervisor.

The findings include:

Review of the facility's policy #MLI0010 titled, "Incident Management: Protection of Patients from Abuse, Neglect, Exploitation, Harassment, and Injury", undated, revealed the purpose of the policy was for the hospital to provide services in a caring and hospitable environment that was free from harm for the patient. Further review of the policy revealed the Risk Management Program was to verify the patients were protected from abuse by providing adequate qualified, trained, and experienced staffing at all times to prevent abuse. Continued review of the policy, under the procedure section revealed the facility sought to protect patients from all forms of abuse by educating staff with the signs and symptoms of abuse and reporting procedures of abuse. Further review of the facility's policy under the Employee Responsibilities section revealed any employee who is involved in or observed an incident, has the responsibility to make an immediate verbal report about the incident, regardless of classification, to the immediate supervisor. Continued review of the policy under the Definitions section revealed "immediately" is defined as: without further delay. In addition, "Incident" is defined as: an occurrence or event that causes, or may cause, harm to an individual(s) served.

Review of the facility's document titled, "Authorizations & Agreements", undated, under patient rights and responsibilities revealed the patient has the right to receive care in a safe environment free from all forms of abuse.

Review of the CPI Education Mannual, undated, revealed under the Crisis Development Model, during anxiety (a noticeable change or increase in behavior) staff should be supportive (an empathic, non-judgemental approach attempting to alleviate anxiety). It states when the patient enters defensive (beginning stage of loss of rationality; verbal acting out) the staff should use a directive (an approach in which a staff member takes control of a potentially escalating situation by setting limits). If further states when the patiet becomes an acting out person (the total loss of control which ogten results in a physical acting out episode) staff should provide non violent CPI (safe non-harmful control and restraint techniques used to safely control an individual until he can regain control).

Review of the facility's Final Expanded Investigative Report, dated 04/18/16, and reveal of the video footage, revealed on 04/09/16 at 3:10 PM, Shift Coordinator #1, by review of video footage of a physical hold that occurred on 04/09/16 at 1:02 PM, discovered Mental Health Associate (MHA) #1 had used excessive force during the physical hold. Further review of the facility's Final Expanded Investigative Report revealed the facility substantiated physical abuse of Patient #1 by MHA #1.

Review of Patient #1's medical record revealed the facility admitted the patient on 05/31/13 with diagnoses of Unspecified Psychosis, Bi-frontal Epilepsy, Autism Spectrum Disorder, and Mild Intellectual Disability.

Observation of Patient #1, on 05/24/16 at 3:11 PM, during initial tour revealed the patient was in the Wendell 3rd floor unit day room talking with two (2) staff members. Patient #1 appeared clean and well groomed with no visible signs of any injury. Continued observation of Patient #1, on 05/25/16 at 8:50 AM, revealed the patient was eating breakfast in the Unit day room.

Review of Patient #1's Restrictive Intervention Report completed by Registered Nurse (RN) #1, dated 04/09/16 at 1:00 PM, revealed Patient #1 was placed in a physical hold restraint at 12:33 PM and released from the restraint at 12:35 PM. Continued review of the report revealed in the nursing progress note section, Patient #1 became agitated and attempted to punch staff because he/she did not want to wear his/her protective helmet. The patient was then placed in a physical restraint for two (2) minutes.

Review of Patient #1's Restrictive Intervention Report completed by RN #1, dated 04/09/16 at 1:30 PM, revealed Patient #1 was again placed in a physical hold restraint at 1:02 PM and released from the restraint at 1:06 PM. Continued review of the report revealed in the nursing progress note section, Patient #1 threw his/her safety helmet at assigned staff member (MHA #1), patient started to kick staff and punch and Patient #1 was put in a hold and taken to bedroom and was released when calm.

Interview, on 05/26/16, at 8:45 AM, with Unit Manager revealed he was not at work the day of the incident involving Patient #1 and MHA #1. Continued interview revealed the Unit Manager reviewed video footage of the incident upon his return to work his next scheduled shift. Continued interview with the Unit Manager revealed what he saw when he reviewed the video footage was he observed Patient #1 while seated on the day room couch, throw his safety helmet at MHA #1 who was seated in an adjacent couch in the day room. MHA #1 blocked the helmet, got up and charged Patient #1 who was still seated on the couch and choked Patient #1. When MHA #2 entered the room, she assisted by holding Patient #1's legs. Patient #1 was released and seemed to be calm. He stated in the day room, it was then Patient #1, MHA #1, and MHA #3. MHA #2 had left the room. The Unit Manager stated the video showed Patient #1 saying something to MHA #1. MHA #1 then went over behind Patient #1 and from behind the couch, choked the patient again. He stated the video showed MHA #1's hands were clearly around Patient #1's neck. The Unit Manager stated MHA #3 was present but didn't seem to have noticed the hold and stated MHA #3 must not have noticed that MHA #1's hands were around the patient's neck, because she did not report anything. Continued interview with the Unit Manager revealed neither of MHA #1's holds where his hands were on the patient's neck, were not something that was taught in the facility's Crisis Prevention Intervention (CPI) class.

Interview by telephone on 05/26/16, at 3:49 PM, with the Shift Coordinator revealed on 04/09/16 a physical hold restraint of Patient #1 was reported to her. The Shift Coordinator revealed she attempted to review the video of the hold when it was reported to her; however, there was something wrong with the video play back system and she could not review it at that time. Continued interview revealed she was able to review the video a couple hours later and it was at that time she discovered excessive force was used by MHA #1. Further interview revealed the Shift Coordinator immediately notified the Administrator on Call (AOC) and Risk Management. Continued interview revealed MHA #1 had already left from the facility due to a work related injury, and he was notified he was being placed on leave due to an expanded investigation. Continued interview revealed when this author asked the Shift Coordinator about the other holds discovered during my investigation, the Shift Coordinator stated that she could not recall any of the other holds that happened that day being inappropriate.

Interview, on 05/26/16, at 10:15 AM, with MHA #2 revealed MHA #1 was involved in four (4) separate physical hold restraints. MHA #2 revealed the first hold was located in front of the nurse's station. MHA #2 observed Patient #1 become physically aggressive towards MHA #1. MHA #2 stated MHA #1 was engaged in a physical hold with Patient #1 so she went to assist. MHA #2 stated when she got up to the physical hold, MHA #1 had one hand on Patient #1's upper shoulder and MHA #1's other hand was on Patient #1's face. Continued interview revealed MHA #2 felt this hold was too forceful of a hold, but she did not report this to the Supervisor. Further interview revealed the second hold was in the dayroom. MHA #2 stated she ran into the dayroom to assist because she heard Patient #1 yelling. Further interview revealed when she got to the day room, she observed MHA #1's hand on Patient #1's neck and face and the patient's face was forcefully shoved down into the couch. Continued interview revealed MHA #2 felt the hold was too forceful and was going to report what she saw to the Charge Nurse once it all calmed down. Further interview revealed MHA #2 did not intervene and did not report what she saw to her supervisor. Continued interview revealed MHA #2 did not witness physical hold number three (3), but did know that it occurred. MHA #2 stated she did; however, witness physical hold number four (4). MHA #2 stated physical hold number 4 was a CPI transport of Patient #1, to his/her bedroom by MHA #1 and MHA #3.

Interview by telephone, on 05/26/16, at 2:30 PM, with MHA #3 revealed she witnessed the physical hold restraints in the dayroom. Continued interview revealed when she returned from lunch, she went into the dayroom and saw that MHA #1 and MHA #2 had Patient #1 in a hold. She stated that MHA #1 had Patient #1's upper body held down, but could not see if MHA #1 was holding Patient #1's shoulders or holding his/her head. Further interview with MHA #3 stating the next thing she remembered was being told by RN #1 to take Patient #1 to his/her room, but didn't remember taking him.

Interview by telephone, on 05/25/16, at 5:25 PM, with MHA #1 revealed Patient #1 threw his/her safety helmet at him, so he went to the patient an put him/her in a hold. Continued interview revealed MHA #1 stated the incident happen so fast he didn't know where his hands were. Further interview with MHA #1 revealed his safety came first over the patient when the patient was acting out. MHA #1 then stated he did not want to talk anymore and hung up.

Interview, on 05/26/16, at 6:10 PM, with the Assistant Chief Nurse Executive revealed his expectations was if any staff member was to even suspect possible abuse, they were to report this to their supervisor immediately. Continued interview revealed, staff was educated on abuse and on reporting abuse.

Based on interviews, record reviews, review of the facility's policies, review of the facility's risk management investigation, review of the facility's Crisis Prevention Intervention Manual (CPI), and review of the facility's video footage with the video review log, it was determined the facility failed to ensure one (1) of ten (10) sampled patients (Patient #1) was free from abuse. In addition, it was determined the facility failed to ensure staff immediately reported suspected and/or actual abuse when on two (2) different incidents a Mental Health Associate (MHA) thought excessive force was used during a physical restraint hold and failed to intervene and report the incident to their supervisor.

The findings include:

Review of the facility's policy #MLI0010 titled, "Incident Management: Protection of Patients from Abuse, Neglect, Exploitation, Harassment, and Injury", undated, revealed the purpose of the policy was for the hospital to provide services in a caring and hospitable environment that was free from harm for the patient. Further review of the policy revealed the Risk Management Program was to verify the patients were protected from abuse by providing adequate qualified, trained, and experienced staffing at all times to prevent abuse. Continued review of the policy, under the procedure section revealed the facility sought to protect patients from all forms of abuse by educating staff with the signs and symptoms of abuse and reporting procedures of abuse. Further review of the facility's policy under the Employee Responsibilities section revealed any employee who is involved in or observed an incident, has the responsibility to make an immediate verbal report about the incident, regardless of classification, to the immediate supervisor. Continued review of the policy under the Definitions section revealed "immediately" is defined as: without further delay. In addition, "Incident" is defined as: an occurrence or event that causes, or may cause, harm to an individual(s) served.

Review of the facility's document titled, "Authorizations & Agreements", undated, under patient rights and responsibilities revealed the patient has the right to receive care in a safe environment free from all forms of abuse.

Review of the CPI Education Mannual, undated, revealed under the Crisis Development Model, during anxiety (a noticeable change or increase in behavior) staff should be supportive (an empathic, non-judgemental approach attempting to alleviate anxiety). It states when the patient enters defensive (beginning stage of loss of rationality; verbal acting out) the staff should use a directive (an approach in which a staff member takes control of a potentially escalating situation by setting limits). If further states when the patiet becomes an acting out person (the total loss of control which ogten results in a physical acting out episode) staff should provide non violent CPI (safe non-harmful control and restraint techniques used to safely control an individual until he can regain control).

Review of the facility's Final Expanded Investigative Report, dated 04/18/16, and reveal of the video footage, revealed on 04/09/16 at 3:10 PM, Shift Coordinator #1, by review of video footage of a physical hold that occurred on 04/09/16 at 1:02 PM, discovered Mental Health Associate (MHA) #1 had used excessive force during the physical hold. Further review of the facility's Final Expanded Investigative Report revealed the facility substantiated physical abuse of Patient #1 by MHA #1.

Review of Patient #1's medical record revealed the facility admitted the patient on 05/31/13 with diagnoses of Unspecified Psychosis, Bi-frontal Epilepsy, Autism Spectrum Disorder, and Mild Intellectual Disability.

Observation of Patient #1, on 05/24/16 at 3:11 PM, during initial tour revealed the patient was in the Wendell 3rd floor unit day room talking with two (2) staff members. Patient #1 appeared clean and well groomed with no visible signs of any injury. Continued observation of Patient #1, on 05/25/16 at 8:50 AM, revealed the patient was eating breakfast in the Unit day room.

Review of Patient #1's Restrictive Intervention Report completed by Registered Nurse (RN) #1, dated 04/09/16 at 1:00 PM, revealed Patient #1 was placed in a physical hold restraint at 12:33 PM and released from the restraint at 12:35 PM. Continued review of the report revealed in the nursing progress note section, Patient #1 became agitated and attempted to punch staff because he/she did not want to wear his/her protective helmet. The patient was then placed in a physical restraint for two (2) minutes.

Review of Patient #1's Restrictive Intervention Report completed by RN #1, dated 04/09/16 at 1:30 PM, revealed Patient #1 was again placed in a physical hold restraint at 1:02 PM and released from the restraint at 1:06 PM. Continued review of the report revealed in the nursing progress note section, Patient #1 threw his/her safety helmet at assigned staff member (MHA #1), patient started to kick staff and punch and Patient #1 was put in a hold and taken to bedroom and was released when calm.

Interview, on 05/26/16, at 8:45 AM, with Unit Manager revealed he was not at work the day of the incident involving Patient #1 and MHA #1. Continued interview revealed the Unit Manager reviewed video footage of the incident upon his return to work his next scheduled shift. Continued interview with the Unit Manager revealed what he saw when he reviewed the video footage was he observed Patient #1 while seated on the day room couch, throw his safety helmet at MHA #1 who was seated in an adjacent couch in the day room. MHA #1 blocked the helmet, got up and charged Patient #1 who was still seated on the couch and choked Patient #1. When MHA #2 entered the room, she assisted by holding Patient #1's legs. Patient #1 was released and seemed to be calm. He stated in the day room, it was then Patient #1, MHA #1, and MHA #3. MHA #2 had left the room. The Unit Manager stated the video showed Patient #1 saying something to MHA #1. MHA #1 then went over behind Patient #1 and from behind the couch, choked the patient again. He stated the video showed MHA #1's hands were clearly around Patient #1's neck. The Unit Manager stated MHA #3 was present but didn't seem to have noticed the hold and stated MHA #3 must not have noticed that MHA #1's hands were around the patient's neck, because she did not report anything. Continued interview with the Unit Manager revealed neither of MHA #1's holds where his hands were on the patient's neck, were not something that was taught in the facility's Crisis Prevention Intervention (CPI) class.

Interview by telephone on 05/26/16, at 3:49 PM, with the Shift Coordinator revealed on 04/09/16 a physical hold restraint of Patient #1 was reported to her. The Shift Coordinator revealed she attempted to review the video of the hold when it was reported to her; however, there was something wrong with the video play back system and she could not review it at that time. Continued interview revealed she was able to review the video a couple hours later and it was at that time she discovered excessive force was used by MHA #1. Further interview revealed the Shift Coordinator immediately notified the Administrator on Call (AOC) and Risk Management. Continued interview revealed MHA #1 had already left from the facility due to a work related injury, and he was notified he was being placed on leave due to an expanded investigation. Continued interview revealed when this author asked the Shift Coordinator about the other holds discovered during my investigation, the Shift Coordinator stated that she could not recall any of the other holds that happened that day being inappropriate.

Interview, on 05/26/16, at 10:15 AM, with MHA #2 revealed MHA #1 was involved in four (4) separate physical hold restraints. MHA #2 revealed the first hold was located in front of the nurse's station. MHA #2 observed Patient #1 become physically aggressive towards MHA #1. MHA #2 stated MHA #1 was engaged in a physical hold with Patient #1 so she went to assist. MHA #2 stated when she got up to the physical hold,