HospitalInspections.org

Based on record review and interview, the facility's governing body failed to carry out responsibilities in accordance with the facility's written policy and procedures to ensure patient rights were protected. The Governing body failed to ensure:

-Patients were protected from on-going physical abuse by removing the alleged perpetrator from patient contact.

-Ensure facility staff followed facility policy and procedure in reporting physical abuse of a patient.

-Ensure nursing staff documented reports of alleged abuse and conducted an immediate physical assessment of the patient after the abuse was made known.

-Ensure all staff, including contracted security officer staffs were trained in Abuse, Negelct, and Exploitation identification and reporting procedures.

This deficient practice placed all patients in the facility at risk for experiencing serious harm and/or injury due to abuse, neglect and/or exploitation..

The cumulative effect of these deficient practices resulted in the facility's inability to meet the Condition of Participation for Governance.

Refer to A0083 and A0145 for evidence of findings.

Based on record review and interview, the facility's governing body failed to carry out responsibilities in accordance with the facility's written policy and procedures to ensure patient rights were protected. The Governing body failed to ensure all staff, including contracted security officer staffs were trained in Abuse, Negelct, and Exploitation identification and reporting procedures.

This deficient practice placed all patients in the facility at risk for experiencing serious harm and/or injury due to abuse, neglect and/or exploitation.

Findings include:

Record review of the facility medical record for Patient #2, dated 08/02/23 at 06:39 am, revealed the following information:

Patient is a 22 y/o Female with a history of depression and bipolar disorder, here voluntarily for suicidal ideation. Pt reports history of previous suicide attempts, reports worsening thoughts of wanting to hurt herself over the last week. Denies attempt prior to arrival here.

Record review of the facility Security Officer Incident Report Records, dated 08/02/23 at 08:18 pm, revealed the following information:

"On 02Aug2023. at approximately 5:05 pm, I, Security Officer (SO) #1 responded to a call In the Transitional Unit (TU) for an agitated patient. When I arrived on the scene, the patient was screaming about how the hospital staff was mistreating her (specifically RN#3). I noticed that nursing staff was behaving In an unprofessional matter. Staff was laughing and behaving In a Juvenile manner. The patient was Suicidal Ideation (SI) at the time and city police was in route to ED her. The TU staff medicated the patient before police arrived and relocated the patient to bed 5 In the ER In order to separate the patient from the TU nurse. While the patient was In the ER, the nurse (RN #3) kept coming Into the ER to turn In paperwork. At that time, I advised charge nurse that she should not let RN# 3 come back Into the ER while the patient was there. This was to prevent possible Instigation from the RN# 3. End of report."

Record review of the facility employee training records for the years of 2022-2023 revealed that nursing staff had been trained in Abuse, Neglect, and Exploitation (ANE) identification and reporting. Further review revealed no evidence that facility contracted Security officer staff had ANE training.


In an interview conducted on 09/22/23 at 1:00pm with the facility Security Director, Surveyor asked the Security Director to clarify if security staff had been given training in Abuse, Neglect, and/or Exploitation identification and Reporting. The Security Director stated, "No, security staffs have not received that training."

Based on record reviews and interviews, the facility failed to ensure that patients are free from all forms of abuse for 2 of 2 patients (patient #1 and #2). The facility failed to:

-Ensure that patients were protected from on-going physical abuse by removing the alleged perpetrator from patient contact.

-Ensure facility staff followed facility policy and procedure in reporting physical abuse of a patient.

-Ensure nursing staff documented reports of alleged abuse and conducted an immediate physical assessment of the patient after the abuse was made known.

This deficient practice placed all patients in the facility at risk for experiencing serious harm and/or injury due to abuse.

The cumulative effect of these deficient practices resulted in the facility's inability to meet the Condition of Participation for Patient Rights.

Refer to A0145 for evidence of findings.

Based on record reviews and interviews, the facility failed to ensure that patients are free from all forms of abuse for 2 of 2 patients (patients #1 and #2). The facility failed to:

-Ensure that patients were protected from on-going physical abuse by removing the alleged perpetrator from patient contact.

-Ensure facility staff followed facility policy and procedure in reporting physical abuse of a patient.

-Ensure nursing staff documented reports of alleged abuse and conducted an immediate physical assessment of the patient after the abuse was made known.

This deficient practice placed all patients in the facility at risk for experiencing serious harm and/or injury due to abuse.

Findings include:

Patient #1

Record review of the facility Security Officer Incident Report Records, dated 05/29/23 at 6:40 am revealed the following information:
-"On Monday 5/29/23 at approximately 6:40 am, charge nurse (RN#1) for the emergency department asked security staff to be on standby while medical staff medicated a patient in the Transition Unit (TU). HSS security officer and I fill in supervisor responded the call for assistance. When security staff arrived at the location, security staff received a report from medical staff. Medical staff stated that the patient was getting aggressive, banging on the door, and was upset screaming at staff. Medical staff asked security staff to be on standby while they medicated the patient. Security staff and medical staff attempted to talk to the patient to deescalate and have him take medication to assist him in calming down. During this time, the patient was upset and became aggressive/combative by trying to kick and punch medical staff. For the safety of staff, security staff, off duty Police officers, and medical staff attempted to restrain the patient hand and legs while in a chair. The patient assaulted Security staff several times by kicking him in the stomach. The patient continued to attempt to assault staff by kicking and punching. During this process of attempting to safely physically restrain the patient, the patient was escorted onto the floor. Once on the floor police officers and medical staff were able to safely restrain patient arms. Security staff safely restrained patient legs. While physically restrained, medical staff was able to medicate the patient safely. Once the patient was medicated, police officer handcuffed the patient to safely escort the patient from the TU to emergency department bed 1, where medical staff requested assistance placing the patient on a 4 point medical restraints. Once the patient was restrained, security was clear from incident, end of report."

Visual Review (No audio or time stamps) of the security video log for the Emergency Room, dated 05/29/23, between the hours of 6:00 am and 7:00 am revealed the following:
- Patient #1 is seen sitting in a reclined geri-chair in a common are within the Emergency Department (ED) psychiatric holding area. He appears to be sitting quietly. Other psychiatric patients are viewed in the video, also lined up in geri chairs sitting quietly in the common area.

- Patient #1 is still sitting quietly reclined in geri-chair. 6 people are then viewed approaching patient #1. (2 nursing staff [RN#1 and RN#2], 2 security staff, and 2 off duty city police officers).

- Patient #1 is viewed speaking with RN#2. At this time, Security staff, off duty officers, and RN#1 are still present and encircled around patient #1's geri chair.

- Patient #1 is still talking to RN #2 and attempts to get up out of his geri chair, using the armchair for support. At this time, Security staff #1 grabs Patient #1 by his right forearm forcefully. Patient #1 starts, pulling away, back into his geri chair and resisting. At this time, RN#1 and Security officer #2 also grab patient #1 and are seen in the video struggling with patient #1 while lying on top of him in the geri chair.

- RN#1 Places Patient #1 into a headlock and then forcefully pulls him out of the geri chair onto the floor. The patient is then in a prone position, face up, with 5 men restraining him while still in the headlock by RN#1. At this time, the head of facility security can be seen in the video, watching the events unfold from behind the glass at the nursing station.

- RN#1 is seen punching patient #1 in the face with a closed fist. Patient #1's glasses fly off his face at this time and land on the floor under a near by geri chair.

-RN#2 witnessed patient #1 get punched in the face and attempts to move RN#1's arm so she can see Patient #1's face. Patient #1 is still in a 5-person restraint on the floor with RN#1's weight on his upper torso. This restraint continues, until patient #1 is turned over onto his stomach, and RN #1 is seen placing his Left Knee on the back of patient #1's left shoulder. At this time, one of the off-duty police officers is seen handcuffing patient #1's hands behind his back.

- Video concludes with patient #1 handcuffed and released from 5 person hold. Patient #1 is then assisted to a standing position by officer and RN#1 while being escorted out of camera frame.

Record review of the medical record for Patient #1 revealed the following:
- "Patient stated that it seems his medication is not working properly and needing to have his medication adjusted. Patient verbalized that he has an outpatient psychiatrist managing his mental illness and was recently switched to Abilify (Psychiatric medication) which he thinks is not working. Per nursing patient has been at the ER for more than 60 hours and patient is requesting to leave so that he can continue his treatment on outpatient basis. Pulmonary consultation was obtained. Patient is calm and engaging in logical manner. Patient reported that he was agitated and a repeat irritable when he came to the hospital but he seems like he is not getting the help that he needs. He is currently requesting to discharge so that he can continue his treatment at site. Patient denies suicidal ideation and homicidal ideation stated that "I am not a danger to anyone or myself' patient lives with his mother and plan to return to his mom's place. Patient denies having homicidal and denies suicidal thoughts or plan."

-Further review revealed no evidence that Patient#1's physician was notified of the witnessed physical abuse of patient #1 that occurred on 05/29/23 and/ or that patient #1 was assessed by nursing staff for injury prior to discharge.

Record review of the facility employment records for RN #1 (Perpetrator) revealed that he was still employed by the facility as of the date of the date of survey 09/22/23 (and in contact with patients). Further review RN #1's employment records revealed the following:
- Document entitled, "Disciplinary/Corrective Action Form," dated 06/08/23.
- Category of Disciplinary action: Conduct, Patient Safety, Policy Violation
- Level of Disciplinary Action: Written (Warning)
-SUSPENSION (If applicable): Blank (nothing written/ checked)
DETAILED SUMMARY OF OFFENSE(S) LEADING TO THIS ACTION:
-"On Monday, May 30, 2023, [This date (5/30/23) is a typographical error which is present in the original document. Document was verified to be for the incident on 5/29/23 with the CNO and facility HR staff] a patient was emergency detained by a physician and medication was ordered. The patient refused the medication and as a result, the Emergency Department team consisting of 3 RNs, 2 Security Officers and 2 Police Officers were present to assist with medication administration. At some point while trying to get the patient to take the medication, he resisted and became physical. The team had to restrain the patient and during this process, one of the RNs shouted to RN #1 (Perpetrator), RN that the patient was going to bite him. Out of reflex. RN #1 struck the patient one time in an effort to prevent the bite."
-"While it may have been a reflex, striking a patient is never appropriate. RN #1 understands this and was apologetic this situation occurred."

In an interview conducted on 09/22/23 from 11:00 am to 12:30 pm with the facility Security Director, Chief Nursing Officer (CNO), and Division Director of Regulatory, The Security Director was asked if she was aware of the incident involving RN#1 which occurred on 05/29/23, (RN#1 striking patient #1 in the ER psychiatric holding area on 05/29/23). She stated, "Yes" further revealing that it had been reported to her by the security staff when nursing staff had called for help subduing a patient in the ER. Surveyor asked Security Director if there was video evidence of the incident from the ER security cameras. The Security Director stated, ""Yes." Surveyor asked if she had viewed the video evidence in question. Both the Security director and the CNO confirmed that they had. The Security Director, CNO, and the Division Director of Regulatory were asked to view the video with the surveyor again. After viewing the video evidence, The CNO was asked by surveyor if an investigation had been conducted, and if so, what was the outcome. The CNO stated that she had conducted an investigation regarding the incident and found that RN#1 had: "Struck the patient out of reflex because he thought the patient was going to bite him." Surveyor then asked if RN#1 was still employed by the facility and in direct patient contact. The CNO stated ""Yes, he is still employed, and had been temporarily suspended." When asked why, CNO stated that she "Did not feel that RN#1 struck the patient on purpose and she believed that it was out of reflex and that RN#1 "had verbalized he was remorseful" about the incident. Surveyor asked the CNO to clarify if nursing staff had been given training in the use of non- violent interventional means to de-escalate mental health patients. She stated they had. Surveyor then asked if striking a patient was part of that training. The CNO stated "No. Striking a patient is never ok." She was then asked if the incident had been reported to the Department of Health and Human Services (was it a self report, etc...), she stated, "No, it has not."

In an interview conducted on 09/22/23 at 12:10 pm the facility Division Director of Regulatory revealed that he was not aware of the incident of alleged abuse that had occurred involving RN #1 striking Patient#1 in the ER on 05/29/23. He further stated that this was her first time viewing the recorded video evidence of the incident. While viewing the video evidence with the surveyor, the Regulatory Director stated, "I don't know if the hand that [RN#1] hit the patient with is his non-dominant hand, or what was said by the patient during the incident as the video lacks audio."


Patient #2

Record review of the facility medical record for Patient #2, dated 08/02/23 at 06:39 am, revealed the following information:
"Patient is a 22 y/o Female with a history of depression and bipolar disorder, here voluntarily for suicidal ideation. Pt reports history of previous suicide attempts, reports worsening thoughts of wanting to hurt herself over the last week. Denies attempt prior to arrival here."

Record review of the facility Security Officer Incident Report Records, dated 08/02/23 at 08:18 pm, revealed the following information:

"On 02 Aug 2023, at approximately 5:05 pm., I, Security Officer (SO) #1 responded to a call In the Transitional Unit (TU) for an agitated patient. When I arrived on the scene, the patient was screaming about how the hospital staff was mistreating her (specifically RN#3). I noticed that nursing staff was behaving In an unprofessional matter. Staff was laughing and behaving In a Juvenile manner. The patient was Suicidal Ideation (SI) at the time and city police was in route to ED her. The TU staff medicated the patient before police arrived and relocated the patient to bed 5 In the ER In order to separate the patient from the TU nurse. While the patient was In the ER, the nurse (RN #3) kept coming Into the ER to turn In paperwork. At that time, I advised charge nurse that she should not let RN# 3 come back Into the ER while the patient was there. This was to prevent possible Instigation from the RN# 3. End of report."

Record review of the facility employee training records for the years of 2022-2023 revealed that nursing staff had been trained in Abuse, Neglect, and Exploitation (ANE) identification and reporting. Further review revealed no evidence that facility contracted Security officer staff had ANE training.

In an interview conducted on 09/22/23 at 12:22pm the facility ER charge nurse revealed that she was familiar with RN #3 and that she had worked with her for a while. When asked by the surveyor if the charge nurse remembered any instances where she had received reports of inappropriate behavior against RN#3, or witnessed RN#3 being verbally or physically inappropriate with patients, the charge nurse stated, "No, I don't remember that, but it's not unusual for nurses in the psychiatric ER transitional unit to be reported by patients for something or be involved in restraints/ complaints." When surveyor asked again if she remembered any complaints against RN#3, The charge nurse stated, "Well, I do remember her being involved in 2 incidents, one with a woman and one with a man, but I don't remember what they were." Surveyor then asked the Charge Nurse what she would do if a staff nurse was reported to her for verbal or physical abuse. She stated, "It would depend on the allegation. I would pull the nurse aside and discuss it with them, then investigate the complaint. If I think it is legitimate I would let the Administrator on Duty (AOD) know."

In an interview conducted on 9/22/2023 at 1:00 pm, the Chief Nursing Officer was asked if there was any documentation (shift notes, etc ...) from the AOD on duty the day of the incident (08/02/2023). The CNO stated, "No, there is nothing like that." When asked if she was aware of the allegation/ incident report regarding the alleged verbal abuse by RN#3, the CNO stated, "No, I wasn't aware of that." When asked if RN#3 was still employed by the facility, the CNO stated "Yes."

Record review of the employment records for RN#3 revealed that she was still employed by the facility as of the date of the survey, 09/22/2023. Further review revealed that RN#3 had been trained in ANE identification and reporting, as well as the use of non- violent interventional means to de-escalate mental health patients.

In an interview conducted on 09/22/23 at 1:00pm with the facility Security Director, Surveyor asked the Security Director to clarify if security staff had been given training in Abuse, Neglect, and/or Exploitation identification and Reporting. The Security Director stated, "No, security staffs have not received that training." The surveyor then asked if security staff had been trained in the use of non- violent interventional means to de-escalate mental health patients. She stated, "Yes they have." During further interview, Surveyor asked if the Security Director was invited/ attended facility Quality meetings or had any direct line of communication with facility upper management in order to discuss security officer's incident reports regarding patient concerns, specifically ANE. She stated, "No. there is really no one who looks at them unless we are made aware." Surveyor then asked what are security staff told to do if they think a patient is being abused? Security Director stated, "They let the Charge Nurse on the unit know about their concerns, then write up an incident report, but no one looks at them unless the shift supervisor lets us know something happened."


Review of the facility adverse event documentation dated 05/01/23 to 9/22/23 revealed no evidence that facility staff reported the abuse to the Department of Health and Human Services.

Record review of the facility policy entitled: REPORTING OF ALLEGATIONS OF PATIENT NEGLECT OR PHYSICAL OR SEXUAL ABUSE OR ASSAULT, reviewed 05/2019, revealed the following information:
SCOPE:
All Facility Healthcare System Staff.
PURPOSE:
To establish a mechanism for recognizing reporting, and the documentation of suspected maltreatment, abuse, neglect, or exploitation in the adult and pediatric populations while on and off all Healthcare system facilities.
DEFINITIONS:
Professional: "an individual who is licensed or certified by the state or who is an employee of a facility licensed, certified, or operated by the state and who, in the normal course of official duties or duties for which a license or certification is required, has direct contact with children. The term includes teachers, nurses, doctors, day-care employees, employees of a clinic or health care facility that provides reproductive services, juvenile probation officers, and juvenile detention or correctional officers".
II. PURPOSE:
The purpose of this policy is to ensure the safety of any individual in a Facility and to ensure that the Administrator on Call immediately and effectively reports allegations of sexual or physical abuse, neglect or assault to the appropriate authorities and within the Company. This policy is intended to cover the reporting of allegations that could involve potential criminal conduct.

A. "Immediate" means at the time of witnessing conduct or receiving an allegation of conduct that is the subject of this policy. The requirements in this policy for "immediate notification" apply even if the incident occurs after hours and/or on weekends and holidays.

B. "Abuse" means any intentional action which harms another person. Abuse includes physical or sexual abuse.

Reporting Criteria:
The Texas Family Code section 101.103 definition: "Child" or "minor" means a person under 18 years of age who is not and has not been married or who has not had the disabilities of minority removed for general purposes. See Texas Family Code section 261.101 for mandated reporting and time requirements.
Persons required to report:
A professional or person having cause to believe that a child's physical or mental health or welfare has been adversely affected by abuse or neglect by any person shall immediately make a report as provided by subchapter B, Section 261.101 of the Texas Family Code.
Reportable Events: Include but are not limited to:
a. Dead on Arrival and Hospital Death within 24 hours of arrival
b. Gunshot wounds or overdose
c. Drowning or near drowning (near drowning is survival after suffocation in water or some other fluid
d. Attempted suicide or controlled substance overdose
e. Sexual Assault/Child/ Elderly or Disabled adult
-Reporting is mandatory for adults >65 or any adult with disabilities and children under the age of 18 with suspicion of sexual assault or abuse.
-Children less than 14 who are pregnant.
f. Human trafficking is mandatory reporting for children under age of 18.

Time to Report:
1. Persons working in MHS facilities must report as soon as possible, but before the end of the shift, upon identification of suspected injury/ reportable incident.
2. Per Texas Family Code, Subchapter B, Section 261.101 (a-d): not later than the 48th hour after the hour the professional first suspects child abuse.

IV. POLICY:
1.) All reporting must be done as soon as possible but before the end of the shift, upon identification of suspected injury/ reportable incident the patient must not be discharged from any facility, department, or clinic within MHS without documentation of Child Protective Services (CPS) or Adult Protective Services (APS), Caseworker Identification number, case number, and other pertinent information related to the incident in the patient's medical record.
2.) Any staff member having reasonable suspicion of maltreatment, abuse, neglect or exploitation will report the suspicion to appropriate authorities defined in this policy. (See Attachments: Risk Factors for Child Maltreatment; and Clinical Indicators of Elder/Disabled Abuse). See policy, Use and Disclosures for which an Authorization or Opportunity to Agree or object is Not Required
3.) Immunity from civil or criminal liability to the reporting party is guaranteed if the report is made in good faith and without malice
4.) Persons required to report cannot delegate or rely on another person to make the report e.g., a nurse or physician must report the abuse rather than writing an order for the social worker to report. Case Management is not responsible for the required reporting; this remains the responsibility of the staff member who first suspects maltreatment.
5.) The Children's Hospital Child Abuse Resource & Educator (C.A.R.E.) earn is available for consult for possible photo-documentation of physical abuse of newborns to 18 year olds. Call the children's emergency room and ask for the charge nurse 5-7777.
6.) All employees are educated on the identification of potential maltreatment during New Employee Orientation, and annually via facility E-day curriculum.
7.) New Employees will also receive additional child specific training and ongoing yearly competency.
8.) Physicians and other Licensed Independent Practitioners receive information on Abuse and Neglect via the Non-Employee Orientation Manual included as part of their credentialing and privileging process.
9.) Volunteers receive education on Abuse and Neglect as part of their on-boarding activities.

PROCEDURE:
1.) All suspected maltreatment must be reported as soon as possible before the end of the reporter's shift to Adult Protective Services. The 24-hour reporting number is 1-800-252-5400 www.dfps.state.tx.us or www.txabusehotline.or
2.) Allegations that occur on facility Premises (adult and pediatric):
Allegations include abuse, neglect, mistreatment or exploitation which occurred in the hospital (employee to patient, patient to patient, patient to employee):The CEO or designee shall take appropriate action to identify and correct unusual or unwarranted utilization patterns on a systemic basis, and shall address each specific use of restraint or seclusion that is determined or suspected of being improper at the time it occurs
a.) Call Police jurisdiction where alleged abuse occurred to investigate, and collect evidence if needed.
b.) b. Report allegation immediately to all of the following:
-Nurse Director/Manager notifies Administration and Legal as appropriate.
-Treating Physician
-Hospital Administrator in house or On-Call
-Quality/Risk Managers
c.) Preserve evidence: do not touch, attempt to clean, or discard anything associated with the allegation. Instruct all who are party to the assault not to shower, go to the bathroom, or change clothes until instructed to do so by staff.
d.) If there is an allegation regarding sexual assault or rape contact the appropriate SANE Nurse immediately.
e.) Complete Occurrence Report by the end of the shift and submit to Quality/Risk Manager and appropriate leadership
7) Maltreatment/Exploitation of the Disabled: (between. 18 years and 65 years of age), Reporting criteria for disabled individuals between the years of 18 and 65 follow reporting of Elder Maltreatment in section 8 above. If the disabled individual is less than 18 years old, follow reporting of Child Maltreatment - see section A above.
8) Violence against an Individual: (Any Age) The following must be reported to the appropriate law enforcement agency having jurisdiction over the place where the incident occurred (not where the patient sought treatment).
a.) Any bullet or gunshot wound treated in the hospital.
b.) Any penetrating wound inflicted upon one individual by another with the intent to harm .
c.) Physical assault of adult is not mandatory reporting inclusive of domestic violence.

31.) SPECIAL PATIENT POPULATIONS
A.) The assessment and reassessment of patients who have special needs secondary to age, disability or specific condition, is tailored to each individual and focuses on data and information specific to the characteristics of each population. All assessment and reassessment data is entered into the permanent medical record.
B.) Special populations are defined as:
1.) Infants, Children and Adolescents
2.) Patients receiving treatment for mental/emotional/behavioral disorders
3.) Patients with alcohol/drug dependencies (MSTH only)
4.) Possible or suspected victims of abuse