HospitalInspections.org

Based on observation, interview, and record review, it was determined the hospital failed to meet the Condition of Participation (COP) for Patient Rights as evidenced by:

The hospital failed to follow its policy and procedure on abuse when: (Refer to A 0145)

1. The hospital did not protect Patient 1 from physical abuse when a Mental Health Worker (MHW) 1 inflicted physical harm to Patient 1 by excessively pushing Patient 1, hitting his head and body on to the wall, and violating Patient 1's rights to be free from abuse.

2. The hospital did not protect all 43 inpatients from potential physical abuse when Mental Health Worker (MHW) 1 who inflicted physical harm to Patient 1 was not separated from the inpatients for four hours after the abuse incident.

3. The hospital did not thoroughly investigate the abuse incident and did not complete the abuse investigation within five days.

4. The hospital did not develop a treatment care plan (a plan in which outlines the proposed goals, plan, and method of therapy) to implement interventions after the identification of the abuse incident.

5. The hospital did not report the abuse incident to the Ombudsman and Adult Protective Services (APS).

6. The hospital did not promptly report the abuse incident to the law enforcement (Police Department/PD).

7. The staff who witnessed and have knowledge of the abuse incident did not take action, communicate, coordinate, and follow up with the Nursing Department and Chief Executive Officer (CEO).

These failures resulted in violating Patient 1's rights to be free from physical abuse, causing severe pain, discomfort, harm, emotional distress, and placing all 43 inpatients to potential physical abuse and harm from the abuser (MHW 1). (Refer to A 0145)

The cumulative effects of these systemic failures resulted in the hospital's failure to provide quality health care in compliance with the Condition of Participation for Patient Rights.

Based on observation, interview, and record review, the hospital failed to follow its policy and procedure (P&P) on "Abuse Identifying, Reporting and Facility Initiated Investigations" when:

1. The hospital did not protect one of 30 sampled patients (Patient 1) from physical abuse when a Mental Health Worker (MHW) 1 inflicted harm to Patient 1 by excessively pushing Patient 1, hitting his head and body on to the wall. This failure resulted in Patient 1 suffering from severe discomfort, pain, and violating his rights to be free from physical abuse.

2. The hospital did not protect all 43 inpatients from potential physical abuse when MHW 1 who inflicted physical harm to Patient 1 was not separated from the inpatients for four hours after the abuse incident. This failure resulted in placing Patient 1 at risk for further physical abuse and placing all 43 inpatients at risk for physical abuse.

3. The hospital did not thoroughly investigate the abuse incident and did not complete the abuse investigation within five days for one of 30 sampled patients (Patient 1). This failure had the potential for all 43 inpatients getting subjected to further abuse incidents.

4. The hospital did not develop a treatment care plan (a plan in which outlines the proposed goals, plan, and method of therapy) to implement interventions after identification of abuse incident for one of 30 sampled patients (Patient 1). This failure resulted in Patient 1 not being protected from further abuse.

5. The hospital did not report the abuse incident to the Ombudsman and Adult Protective Services (APS) for one of 30 sampled patients (Patient 1). This failure had the potential for abuse incidents not reported accordingly to the appropriate agencies.

6. The hospital did not promptly report the abuse incident to the law enforcement (Police Department/PD) for one of 30 sampled patients (Patient 1). This failure had the potential for all inpatients not getting the full protection from MHW 1.

7. The staff who witnessed and have knowledge of the abuse incident did not take action, communicate, coordinate, and follow up with the Nursing Department and Chief Executive Officer (CEO). This failure resulted in Patient 1 not being protected from physical abuse, abuse incident not investigated, and placing all 43 inpatients to potential physical abuse.

Findings:

1. During a review of the hospital's "Self-Report", dated 12/31/21, the "Self-Report" indicated, "An event occurred, involving an employee [MHW 1] and patient [1] on 12/29/21; in which MHW [1] used an unapproved intervention while attempting to place patient [1] in the seclusion room [involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving]."

During a review of Patient 1's "Psychiatric Evaluation (PE)", dated 12/28/21, the "PE" indicated, "The patient is 43-year-old male who is in the hospital on involuntary hold. He has a working diagnosis of major depressive disorder [a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life], recurrent psychotic features [a mental disorder characterized by a disconnection from reality]. He requires ongoing treatment with stabilization."

During an interview on 1/7/22, at 1:43 PM, with Chief Nursing Officer (CNO), CNO stated, on 12/30/21, she was reviewing the hospital's surveillance video (dated 12/29/21), of the seclusion room. CNO stated she saw MHW 1 excessively pushed Patient 1 to the wall and hit his (Patient 1) head on to the wall. CNO stated, she was the one who discovered the abuse incident the next day (12/30/21), when she routinely reviewed the hospital's surveillance videos. CNO stated, according to her initial investigation, no one witnessed the abuse incident and no one reported the incident.

During an observation, interview, and review of the hospital's video surveillance, on 1/7/22, at 2 PM, in the conference room, with the CNO and Risk Manager (RM), the video surveillance dated 12/29/21, at 3:04 PM, was reviewed. In the video, there was a tall man wearing a scrub suit and a gray beanie hat. CNO stated he was identified as MHW 1, and there was another shorter man wearing a long sleeved shirt and long pants. CNO stated he was identified as Patient 1. MHW 1 was observed taller and had bigger body built than Patient 1. It was noted on the video, MHW 1 and Patient 1 was observed inside the seclusion room. MHW 1 was standing by the door, and Patient 1 was attempting to leave the seclusion room, and walked towards MHW 1. MHW 1 was observed excessively pushed Patient 1. Patient 1 fell across the room, and on to the wall (distance was measured 9 feet, 11 inches). Patient 1's body and head hit the wall, and fell to the floor, and was holding his head in severe discomfort. MHW 1 slammed the door shut, leaving Patient 1 on the floor.

During an interview on 1/7/22, at 3:07 PM, with MHW 2, MHW 2 stated, "I saw he [Patient 1] was running to the door, I saw [MHW 1] pushed him and slammed the door. Everybody was there, we were all standing outside by the door." MHW 2 stated, the Director of Social Services (DSS) was there, other MHWs, and nurses were there.

During an interview on 1/7/22, at 3:39 PM, with Director of Social Services (DSS), DSS stated, "He [MHW 1] pushed the patient [1] and closed the door. I walked away."

During an observation on 1/12/22, at 10 AM, in the seclusion room, it was noted the door had a glass window, a non-movable wooden bed was in the middle of the room. The distance of the door to the wall was measured 9 feet and 11 inches (where Patient 1 was pushed from the door to the wall).

During an interview on 1/12/22, at 11:18 AM, with MHW 1, MHW 1 stated, "The patient [1] was trying to come out of the seclusion room. I just used my size to keep him from running out, I gave him a push." MHW 1 stated, "I have been working out [exercise to improve strength] and everything was just so light." MHW 1 stated, he shut the door closed after pushing Patient 1. MHW 1 stated, "I saw him hit the wall and fall but I don't speak Spanish, so I did not go check on him. Then I realized, oh men this can't be good." MHW 1 stated, he did not know the right technique how to handle patient who walks towards him. MHW 1 stated, "I got paranoid, I thought he was going to attack me. So, I pushed him [Patient 1]."

During an interview on 1/18/22, at 9:16 AM, with MHW Educator (MHWE), MHWE stated, "I train staff of "Handle with Care". No staff should be ever pushing any patient or do excessive force. I saw the video surveillance and the MHW [1] pushed the patient [1] excessively and is unacceptable." MHWE stated, the technique being taught was to have the patient safely away from the door before closing, de-escalate situation (reduce intensity of a violent situation) and blocking technique does not include pushing. MHWE stated, "Anything excessive [force] is abuse."

During a review of the hospital's P&P titled, "Abuse: Identifying, Reporting, and Facility Initiated Investigations" dated 8/20/21, the P&P indicated, "Patients have the right to be free from abuse or neglect as well as fear of being abused or neglected."

2. During an interview on 1/7/22, at 3:39 PM, with DSS, DSS stated, "He [MHW 1] pushed the patient [1] and closed the door. I walked away." DSS stated, she did not separate MHW 1 from Patient 1 and other patients. DSS stated, she did not separate or sent MHW 1 home because it was the responsibility of the nursing department to investigate and send the abuser home.

During an interview on 1/7/22, at 3:54 PM, with Registered Nurse (RN) 1, RN 1 stated she was Patient 1's nurse during the abuse incident. RN 1 stated, "I did not see what happened [abuse incident], no one told me." RN 1 stated, she heard a sound and she looked by the glass window of the seclusion room door and saw Patient 1 on the floor holding the back of his head. RN 1 stated, she did not ask the staff who witnessed the abuse incident of what happened and how Patient 1 fell. RN 1 stated, she documented the incident as a fall incident. RN 1 stated, MHW 1 was not sent home and worked the rest of his shift (another 4 hours). RN 1 stated, she was unaware of the abuse incident until the CNO showed her the video surveillance the next day (12/30/21).

During a review of Patient 1's "Nursing Progress Notes (NPN)", dated 12/29/21, at 5:45 PM, the "NPN" indicated, "While trying to keep patient [1] in seclusion, patient [1] fell backwards and hit back [sic] of his head on the wall."

During a review of the hospital's P&P titled, "Abuse: Identifying, Reporting, and Facility Initiated Investigations" dated 8/20/21, the P&P indicated, "A. Staff members suspected or accused of abuse or neglect will be sent home pending the outcome of the investigation."

3. During an interview on 1/7/22, at 4 PM, (seven days after the discovery of the abuse incident), with CNO, CNO stated, the facility had not completed the investigation. CNO stated, she was unaware there were witnesses of the abuse incident.

During an interview on 1/13/22 at 4 PM, (13 days after the incident), with CNO, CNO stated, the investigation report was to be completed by the RM. CNO stated, the investigation report has not been completed yet, and should have been completed in 5 days.

During a review of the hospital's P&P titled, "Abuse: Identifying, Reporting, and Facility Initiated Investigations" dated 8/20/21, the P&P indicated, "Allegations and information indicating that abuse or neglect may have occurred will be thoroughly and promptly investigated with appropriate follow-up action taken."

4. During an interview on 1/12/22, at 10:41 AM, with Registered Nurse Supervisor (RNS), RNS stated, "I was not aware of the abuse incident until they showed me the surveillance video. I did not develop a treatment care plan because they [CNO and RM] did not tell me to make one."

During a concurrent interview and record review, on 1/13/22, at 9:20 AM, with RN 1, Patient 1's Treatment Care Plan, dated 12/30/21, was reviewed. RN 1 stated she did not develop a treatment care plan for the abuse incident. RN 1 stated, she did not document anything because she was not assigned with Patient 1 the next day (12/30/21),when she was notified of the abuse incident.

During an interview on 1/13/22, at 9:30 AM, with CNO, CNO stated, treatment care plan was not developed. CNO verified the findings.

During a review of the hospital's P&P titled, "Multidisciplinary Treatment Planning" dated 8/20/21, the P&P indicated, "ii. When initiating the Individualized Care Plan, the RN shall include at least the following: 1. A problem list identifying: c. safety issues not included in the principal or medical problems above."

5. During a concurrent interview on 1/18/22, at 10:52 AM, and review of facility's P&P on "Abuse: Identifying, Reporting, and Facility Initiated Investigations", dated 8/20/21, with RM, RM reviewed the facility's P&P and stated, "We did not report the incident to the Ombudsman and APS."

During a review of the hospital's P&P titled, "Abuse: Identifying, Reporting, and Facility Initiated Investigations" dated 8/20/21, the P&P indicated, "B. All mandatory reports shall be made to the appropriate body, APS, CPS [Child Protective Services], Ombudsman, CDPH [California Department of Public Health], and Law Enforcement (if indicated)."

6. During a concurrent interview and review of the hospital's policy and procedure (P&P), on 1/18/22, at 10:52 AM, with RM, RM reviewed the hospital's P&P and stated, the abuse incident was not reported to the PD promptly. RM stated, the abuse incident was reported to the PD on 1/12/22 (12 days later).

During a review of the hospital's P&P titled, "Abuse: Identifying, Reporting, and Facility Initiated Investigations" dated 8/20/21, the P&P indicated, "B. All mandatory reports shall be made to the appropriate body, APS, CPS, Ombudsman, CDPH, and Law Enforcement (if indicated)."

7a. During an interview on 1/7/22, at 1:43 PM, with CNO, CNO stated, "Nobody reported the abuse incident to me [on 12/29/21] until it was discovered on the video surveillance on 12/30/21."

During an interview on 1/7/22, at 3:07 PM, with MHW 2, MHW 2 stated he witnessed the abuse incident (on 12/29/21). MHW 2 stated, "I did not report what happened because all those people [DSS and nurses] above me [staff with higher position] were there." MHW 2 stated he could have discussed and reported the abuse incident to his supervisor, but he did not. MHW 2 stated, he did not know the nurses were unaware of the abuse incident.

During an interview on 1/7/22, at 3:39 PM, with DSS, DSS stated, she witnessed the abuse incident (on 12/29/21), and she reported the abuse incident to the Director of Clinical Social Services (DCSS) but she did not receive any direction from DCSS what to do next, and she did not notify the nursing department. DSS stated, she did not communicate with RN 1 and/or Registered Nurse Supervisor (RNS). DSS stated, it is the responsibility of the nursing department to investigate and document, but she did not know the nurses were unaware of the abuse incident.

During an interview on 1/7/22, at 4:04 PM, with DCSS, DCSS stated, he received a phone call from DSS stating DSS felt MHW 1 did too much force to Patient 1. DCSS stated, he did not follow up the next day. DCSS stated, usually, the nursing department does the investigation, documenting, and reporting. DCSS stated, he did not know the nursing department was unaware of the abuse incident.

During an interview on 1/12/22, at 10:41 AM, with RNS, RNS stated, "No one reported the abuse incident to me. I was not aware of the abuse incident until they showed me the video surveillance. If I have known it, I would have reported, investigated, and sent the MHW [1] home."


18790


7b. During a concurrent interview and record review, on 1/12/22, at 2:38 PM, with DSS, DSS stated, "On 12/29/21, about 3:10 PM, I was physically present at the videotaped seclusion room shove by MHW [1], to Patient 1. I was standing behind [MHW 1], three or four feet behind. Patient [1] was sitting on the floor. Patient [1] jumped up and tried to rush the door. MHW [1] shoved Patient [1] down to the floor and MHW 1 went outside the seclusion room." DSS stated "I notified my supervisor, [DCSS] immediately. DSS stated she did not notify the nursing department about the abuse incident.

During a concurrent interview and record review, on 1/13/22, at 8:35 AM, with DCSS, DCSS stated, "I received a phone call from DSS. It was, essentially, 1. lots of people involved. 2. Too much force. I didn't know what kind of force, physical force, verbal force, or too many people showed up for code." DCSS stated she asked DSS if nursing department were involved and DSS informed her the nursing staff were standing next to DSS when the incident happened. DCSS stated DSS informed her she thought an investigation and report would be done, because the nurses were aware. DCSS stated the next day, 12/30/21, "[CNO] had video footage of the incident. . .then it occurred to me that the incident was physical abuse. . .that the patient [1] had been shoved across the room." DCSS reviewed the hospital's "Investigative Process Flow Map" and stated, "The incident was a sentinel event [patient safety event that resulted in severe harm]." DCSS stated, he also did not notify the Chief Executive Officer (CEO) as the flow map's line of authority indicated.

During an interview on 1/13/22, at 9:40 AM, with CEO, CEO stated, "On 12/30/21, I was requested to come to the RM desk to see a video. I saw a seclusion event in progress, where MHW [1] pushed Patient [1] as Patient [1] was trying to leave the seclusion room. It was very clear to see it was MHW [1] who pushed Patient [1] down. I was unaware of the event." CEO stated DCSS "should have notified me immediately."

During an interview on 1/14/22, at 11:10 AM, with MHW 3, MHW 3 stated, he was aware of the incident and he asked MHW 1 why he pushed Patient 1 hard. MHW 1 told MHW 3 he (MHW 1) thought Patient 1 was coming to attack. MHW 3 was asked if the charge nurse was made aware of the incident. MHW 3 stated, "No."

During a review of the hospital's P&P titled, "Abuse: Identifying, Reporting, and Facility Initiated Investigations" dated 8/20/21, the P&P indicated, "Investigation Review Committee - A review committee is made up of two or more leaders from appropriate departments, which may include the Chief Executive Officer, Medical, Nursing, Quality/Risk Management, Administrator on Call, or Clinical Services for the purpose of reviewing an investigation and/or development of a risk assessment or plan of correction if needed related to allegations or incidents of internal abuse/neglect. A. All employees who witness or who have knowledge of suspected internal patient abuse during admission, shall immediately notify their direct supervisor, the CNO, or the Quality Assurance/Risk Department."