HospitalInspections.org

Based on interview, record review, and review of facility abuse policy, it was determined the facility failed to ensure patients were protected from abuse for three (3) of twenty-three (23) sampled patients. Patient #3 was verbally abused by a security guard. Patient #2 was physically abused by a security guard. Patient #4 was sexually abused by a security guard.

The findings include:

Review of facility policy, "Abuse, Neglect, Exploitation of Patients and Reporting", adopted May 2017, revealed the purpose of the policy was to ensure patients were free from all foms of abuse, neglect, harassment or exploitation from staff, volunteers, other patients or visitors. Continued review of the policy revealed any person having reasonable cause to suspect that a patient who is a vulnerable adult (defined as a person eighteen (18) or older who, because of mental or physical dysfunctioning is unable to manage his or her own resources, carry out the activity of daily living, or protect himself or herself from neglect, exploitation, or a hazardous or abusive situation without assistance from others, and who may be in need of protective services) or child has suffered abuse, neglect, or exploitation shall report or cause report to be made in accordance with Kentucky State Law. Finally, policy review revealed an oral or written report shall be made to the Cabinet for Health and Family Services (CHFS) immediately upon knowledge of suspected abuse, neglect, or exploitation.

1. Patient #3 was admitted to the facility on 01/12/2022 with diagnoses to include Shizoaffective Disorder Unspecified, with delusions and impulse control issues.

Review of a Final Expanded Investigative Report from the facility dated 01/12/2022 revealed on 12/31/2021 Patient #3 reported to staff that Security Guard #1 had called him/her a bitch. Report revealed Security Guard #1 was immediately interviewed and admitted to calling Patient #3 a bitch in response to Patient #3 calling him an assortment of names. Security Guard #1 was suspended following interview.

Continued review of the Investigative Report revealed the facility contacted Patient #3's responsible party, and notifed Adult Protective Services (APS) and the Office of Inspector General (OIG). Security Guard #1 was allowed to return to work at a later date as behavior was not characteristic of his typical work with patients, under conditions that he be re-educated on facility policy related to abuse, he not have assignments on the unit where Patient #3 is boarded, and he not respond to any code green (a patient behavioral episode requiring staff intervention, potentially including restraint) on the unit, to prevent contact between he and Patient #3.

Interview with the Executive Director (ED) of the behavioral health unit, on 02/15/2022 at 9:24 AM, revealed Patient #3 had been taunting Security Guard #1 when the guard reacted and called Patient #3 a bitch. He went on to reveal Security Guard #1 was a relatively new employee, and was apologetic. Following retraining, he was allowed to keep his position, with the stipulation that he not be assigned to any location Patient #3 was located.

Interview with Patient #3 on 02/16/2022 at 2:39 PM revealed he/she perceives staff frequently call him/her names, and defends other staff when he/she makes accusations against them.

Interview with RN #6 on 02/16/2022 at 2:42 PM revealed Patient #3 gets argumentative and mad if staff don't do exactly what he/she wants, and will threaten to get staff fired. RN #6 stated she does not believe Patient #3 is picked on by other patients or by staff.

Interview with RN #7 on 02/16/2022 at 2:46 PM revealed she reported the allegation of verbal abuse by Security Guard #1 against Patient #3 to the house supervisor. She revealed she had been doing rounds when Patient #3 reported to her and when confronted by RN #7, Security Guard #1 admitted to calling Patient #3 a bitch. Further review revealed Security Guard #1 was never on the unit after she reported the allegation.

Attempts to interview Security Guard #1, who no longer worked on the unit where the incident was reported, were unsuccessful. He declined to speak to the surveyor without approval of his attorney. Interview with Security Guard #1's attorney, on 02/17/2022, revealed his client did not wish to speak with the surveyor.

2. Review of Patient #2's medical record revealed Patient #2 was admitted to the facility on 04/26/2020 with diagnoses to include Shizoaffective Disorder Bipolar Type, with a medical history of Acute Psychosis and Asperger's Syndrome.

Review of a Final Expanded Investigative Report dated 01/14/2022 revealed it was alleged on 01/02/2022 that Security Guard #2 struck Patient #2 in the jaw and grabbed the patient by the neck during a code green incident. Continued review of the report revealed Security Guard #2 entered the dayroom with a cup of coffee where patients were getting snacks. Patient #2 asked for additional snacks, then coffee, and when denied by Security Guard #2, Patient #2 physically attacked Security Guard #2. Both Security Guard #2 and Security Guard #3 took Patient #2 to the ground using Non-Violent Crisis Intervention (NVCI). Patient #2 alleged Security Guard #2 punched him/her in the jaw; although Security Guard #2 denied the allegation, Security Guard #3 confirmed Security Guard #2 did in fact punch Patient #2 in the jaw. Security Guard #3 also stated once Patient #2 was on the ground, Security Guard #2 placed his hand around Patient #2's neck.

Continued review of the facility's investigation revealed the facility contacted Patient #2's responsible party, and notified Adult Protective Services (APS) and the Office of Inspector General (OIG). Security Guard #2 was immediately suspended and later terminated from the contracting agency. X-rays were conducted of Patient #2's jaw with no injuries noted. Security staff were re-educated regarding the facility's abuse policy. As this had been the second incident involving inappropriate behaviors from contracted security staff, additional training was developed and completed with all security staff by 02/01/2022 to include the abuse policy, communication and de-escalation skills training, role-play scenarios to avoid personal escalation, and information related to legal consequences of inappropriate behaviors.

Interview with the ED on 02/15/2022 at 9:24 AM, and again on 02/17/2022 at 10:32 AM, revealed the facility substantiated physical abuse. The ED stated even though Security Guard #2 denied the allegation, and facility staff did not have a clear view of exactly what occurred, based on the allegation by the patient, and corroboration by Security Guard #3, Security Guard #2 was immediately suspended and later terminated. The ED went on to reveal, as facility determined there were incidents occuring in snack line while patients waited for coffee, coffee is no longer available in the snack line, and is instead provided with meals so patients don't stand in line for it. Continued interview revealed there had been no further incidents with Patient #2 in the snack line following this change. The ED further stated there is an upcoming case conference with the State Director for Behavioral Health, and the facility will be seeking other suggestions regarding Patient #2's behaviors.

Interview with Patient #2 stated he/she was trying to show Security Guard #2 his/her fingerprints on 12/31/2021 when Security Guard #2 hit him/her, knocked him/her down, and put him/her in seclusion. Patient #2 stated he/she was screaming at Security Guard #2 at the time.

Interview with RN #7 on 02/16/2022 at 2:46 PM revealed Patient #2 historically has violent outbursts, and although she was not working on 12/31/2021, she heard about the incident, and that patient #2 was not injured. She revealed Patient #2's behaviors make it difficult to secure alternate facility placement for him/her, and due to his/her behaviors the facility has security guards to protect Patient #2 and to protect other patients from Patient #2.

3. Patient #4 was admitted to the facility on 01/24/2022 with diagnoses to include Bipolar Disorder Depressed, as patient was feeling suicidal and wanted help with his/her medications. Patient #4 was discharged to a lower level of care on 01/27/2022 following stabilization.

Review of Intake Information revealed Patient #4's guardian was notified Patient #4 had been sexually assaulted in the evaluation area by Security Guard #1 on the night of 01/24/2022. However, a report was not made to Adult Protective Services (APS) or the Office of Inspector General (OIG) until the following day, 01/25/2022.

Review of Patient #4's medical record revealed a note dated 01/25/2022 at 3:08 PM which indicated APS had been notified of the allegation.

Interview with the ED, on 02/15/2022 at 9:24 AM and again on 02/17/2022 at 11:32 AM, revealed he was limited in what documentation he could provide regarding the sexual abuse investigation involving Patient #4, as there is current litigation. He revealed Security Guard #1 had already finished his shift prior to Patient #4 reporting. He stated Security Guard #1 was immediately suspended by the facility, and terminated by the contracting security company. Continued interview revealed following the report staff responded appropriately, aside from administrative staff failing to call APS until the following day.

Review of the Inservice, "Abuse Reporting when not an RUI (Report of Unusual Incident)", which included the facility policy related to abuse and reporting, revealed administrative staff completed the inservice by 01/28/2022.

Continued interview with the ED on 02/17/2022 at 11:32 AM revealed, as the evaluating nurse closing the office door for privacy when obtaining orders was identified as a factor that contributed to providing opportunity for Security Guard #1 to sexually abuse Patient #4, a new process was immediately implemented (01/25/2022) whereby the evaluating nurse will call the house supervisor, who would either come to the unit or arrange for another staff member to come to the unit to be outside the door while the evaluating nurse is getting orders. The ED revealed all house supervisors, as well as evaluating nurses, were educated on this new process. Continued interview revealed additional education was provided to all security guards on 01/26/2022.

Interview with the Director of Risk and Compliance (DRC), on 02/17/2022 at 10:01 AM, revealed following the 12/31/2021 incident when Patient #3 was verbally abused, and the 01/02/2022 incident in which Patient #2 was physically abused, security staff throughout the building were re-educated; however, not all staff were educated as the facility considered this to be an issue with contracted security staff. Regarding the sexual abuse alegation by Patient #4 on 01/24/2022, the DRC revealed in addition to security staff being re-educated, administrative staff were re-educated on proper reporting.

Interview with the ED on 02/17/2022 at 11:32 AM, and again at 3:34 PM, revealed security guards were re-educated on abuse and neglect following the incidents with Patient #3 and Patient #2. Security guards were again educated after the incident with Patient #4, this time not just on abuse and neglect, but on boundaries and on dealing with their own anxiety and frustration. In addition, administrative staff were re-educated on reporting abuse, and house supervisors and evaluation nurses were educated on a new process to ensure patients were supervised by facility staff in the evaluation unit when nurses had to close the door to obtain orders. As security staff were the identified perpetrators in all three situations who failed to follow facility policy, and psych staff acted appropriately, he did not feel psych staff needed to be educated following the incidents. He revealed pscyh staff are educated regularly, often twice a year, with staff last educated in October 2021. He went on to reveal the facility could re-educate staff on abuse and neglect policy.

Interview with the Director of Nursing (DON) for the Psychiatric Center, on 02/17/2022 at 3:52 PM, revealed staff had completed abuse training in October 2021, and had responded appropriately in all three situations. She revealed the contracted security staff were the ones who failed to follow policy, which was the reason they received re-education. She revealed if a nurse or an aide were at fault or failed to act appropriately, then all staff would have been educated. Regarding training of staff who may be sent to the evaluation unit to provide supervision, the DON revealed staff would be informed by the house supervisor of the need to go to the evaluation unit to provide supervision while the nurse took orders. She revealed this was the same as the process on other units, and would not have to be individualized for other staff. Regarding the possibility of another staff member acting as the evaluating nurse when one is not present, she revealed new hires are trained on orientation, and there is a very descriptive process of how evaluations work, which will include the new process put into place.

Subsequent interview with the DRC, on 02/17/2022 at 4:07 PM, revealed her expectation abuse is not tolerated, and staff are to be trained on the facility's abuse policy. She stated as psych staff are trained often, and responded appropriately, the need to re-educate them was not considered. The DRC acknowledged staff could always benefit from increased training. Further, she stated training could be beneficial for psych staff who could potentially be pulled to act as an eval nurse, or to the unit to provide supervision. She stated it never hurts to educate.

Based on interview and record review, it was determined the facility failed to maintain confidentiality of patient records for two (2) of twenty-three (23) sampled patients, Patient #23 and Patient #24.

The findings include:

Review of Patient #23's medical record revealed the patient was admitted to the facility on 05/14/2019 for surgical evaluation of a foreign body in his/her rectum. Hospital staff surgically removed the foreign body and Patient #23 was discharged from the facility on 05/17/2019. An x-ray was conduted prior to surgery; following extraction, the object was photographed for clinical evidence.

Patient #24 entered the facility on 03/03/2020 following an accidental gunshot wound to the nose. A Computed Tomography (CT) scan was obtained to evaluate for intracranial injury. Patient #24 was not admitted, and was instead transferred to another facility for care.

Review of an allegation received on 11/02/2021 revealed the complainant alleged RN #2 had sent him/her x-ray images of a patient with a foreign body in his/her rectum (who was later identified based on the images provided by the complainant as Patient #23), along with prejudicial remarks regarding said patient's sexuality. The complainant also alleged RN #2 sent him/her x-ray images of a patient who had shot himself/herself in the head, along with comments the patient was too stupid to kill himself/herself. (The Director of Risk Compliance (DRC), after researching photos of the X-rays sent to the complainant, and provided by the surveyor, confirmed the X-rays belonged to Patient #24)

In an interview with RN #2, on 02/16/2022 at 8:55 AM, she admitted to having pictures of patient x-rays on her cell phone, but stated she received them from other staff, and never sent any pictures out. RN #2 stated the complainant may have accessed her cell phone in the past and sent said pictures out. RN #2 stated the images on her phone did not have any patient identifiers on them, and she was previously unaware having patient photos was a violation of policy.

Review of the facility's policy entitled "HIPAA - De-Identification of Protected Health Information", adopted 11/11/2011, revealed the Chief Privacy Officer or the Office of Legal Affairs were authorized under HIPAA, 45 CFR Parts 160 and 164, to de-identify protected health information without consent or authorization provided there was no reasonable basis to believe the information could be used to identify a patient.

Review of the facility's policy "Photographing, Filming or Videotaping Patients", not dated, under the section on Patient Consent, revealed if a photograph is to be disclosed outside of the facility for purposes other than treatment, payment, or operations and will not be de-identified, a valid HIPAA authorization must also be signed by the patient or patient representative. Continued review revealed, under the section on Clinical Photography, the use of cell phones as imaging or recording devices is strictly prohibited by hospital staff.

Interview on 02/15/2022 at 7:58 AM, and again at 1:19 PM, with the DRC, revealed she was responsible for ensuring privacy and confidentiality of patient records. She revealed it was a violation of policy to send photos of x-rays over cell phones. Once images provided by the complainant were shared with the DRC, she revealed RN #2 was the only staff member present for the admission of Patient #23, and was present when Patient #24 came through the emergency department.

Continued interview with the DRC, on 02/16/2022 at 9:41 AM and again on 02/17/2022 at 4:07 PM, revealed RN #2 stated another staff member had sent her the images in question, that she had never sent the images out, and that the complainant would send himself/herself texts from RN #2's phone. The DRC stated her expectation is that confidentiality is maintained and HIPPA is followed, and she would not expect staff to have pictures of x-rays or anything in the faciltiy on their cell phones.