HospitalInspections.org

Based on observation, interview, record review and policy review, the facility failed to:
- Protect one patient (#9) of one patient on the Geriatric Psychiatric unit (a unit for treatment of psychiatric illnesses in the elderly) from physical and emotional abuse when a staff member placed a squeaky dog toy (a plastic dog toy used as a call light) in the patient's mouth. ( Refer to A-0145)
- Protect patients from the alleged perpetrator by allowing her to continue to work the remainder of her shift and two additional shifts following an incident of physical and emotional abuse; (Refer to A-0144)
- Follow their internal policies on Allegations of Abuse or Neglect; (Refer to A-0145)

The severity and cumulative effect of these deficient practices resulted in the facility's non-compliance with the requirements found at the Condition of Participation: Patient's Rights. The facility census was nine.



















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Based on interview and record review the Governing Body (GB) failed to ensure that their responsibility to review and resolve grievances was delegated in writing to a grievance committee. This failure could potentially endanger all patients if allegations were not investigated for systemic problems that could lead to patient harm. The facility census was nine.

Findings included:

1. Record review of the facility policy titled, "Grievance Procedure-Patient Complaints and Grievance Process," dated 12/2015, showed the GB had ultimate oversight responsibility for the grievance process and the initial grievance investigation and management was delegated as the direct responsibility of the Chief Executive Officer (CEO.)

2. Record review of the GB meeting minutes dated 03/25/15, 06/24/15, 08/26/15, and 09/22/15 showed no evidence that the GB delegated the grievance process to a grievance committee.

During an interview on 01/26/16 at 3:15 PM Staff A, Quality Risk Manager, stated that there was no grievance committee.

During an interview on 01/27/16 at 4:37 PM Staff W, Chairman of the Board, stated that the GB delegated the authority to the CEO for the grievance process and the grievances did not go directly to the GB for review and resolution.

Based on interview, record review and policy review, the facility failed to provide a safe environment on the Geriatric Psychiatric unit (Geri Psych unit used to treat psychiatric illnesses of the elderly) by allowing an alleged perpetrator (Staff H) to continue to work following an incident of alleged physical and emotional abuse of one of one patient (#9). The failure to remove the alleged perpetrator from patient care resulted in an unsafe environment for all patients and had the potential to place all patients within the facility at risk for abuse. The facility census was nine.

1. Record review of the facility policy titled, "Allegations of Abuse or Neglect" revised 03/2015 showed that all patients have the right to be free from abuse or neglect as well as the fear of being abused or neglected.
Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish or mental illness.
- Types of Abuse:
- Physical: An act that results, or has the potential to result in death, pain, temporary or permanent disfigurement, or impairment of any bodily organ or function. Examples include, but are not limited to rough handling, hitting, slapping, pinching, pushing, shoving, kicking, and controlling behavior through corporal punishment.
- Emotional or psychological: An act which results, or has the potential to result in mental impairment of a patient's intellectual or psychological functioning. Examples include, but are not limited to humiliation, harassment, imitating or mocking behavior, inappropriate threats of punishment or deprivation, use of derogatory nicknames.

2. Record review of Patient #9's medical record showed in the Discharge Summary the patient was an elderly female who was admitted to the facility on 11/20/15 for worsening dementia (memory loss) with increased aggression. She was pacing, had high anxiety, cried easily and was confused.

3. During an interview on 01/25/16 at 2:30 PM, Staff C, Director of Geri Psych, stated that:
- She learned Monday (11/23/15) morning that Staff H, Patient Care Tech (PCT), had placed a squeaky dog toy (a dog toy, which was used by the unit as a call light and looked like a tree branch. It was approximately seven and a quarter inches long and was graduated in length from one and a quarter inches to one half inches wide. It emitted a squeaky noise when squeezed.) into a patients mouth to prevent the patient from biting while being dressed.
-This had happened in the early morning hours on 11/22/15 on the Saturday night shift (11/21/15) and she learned of it because the staff was upset because Staff H was joking about the incident.
- Staff H worked the rest of the week but couldn't work alone or without the supervision of another staff.

During a telephone interview on 01/26/16 at 9:55 AM, Staff J, Registered Nurse (RN), Charge Nurse, stated that:
- He heard yelling and went to the room where Staff H and Staff I were with the patient.
- The patient was kicking and trying to bite.
- Staff H put the squeaky dog toy in the patients mouth.
- He did not consider putting the squeaky dog toy in the patient's mouth abuse.

Staff J took no action to remove Staff H, PCT, from patient care after he was aware of physical abuse with Patient #9.

During a telephone interview on 01/26/16 at 4:00 PM, Staff S, RN, stated that:
- She was acting as the day House Supervisor on 11/22/15 and was called to the Geri Psych unit.
- She was told by a day PCT, Staff V, that Staff H, a night PCT, had placed a squeaky dog toy in a patient's mouth.
- She thought the act was degrading to the patient and had she witnessed the incident she would have called management but she heard of it second and third hand.

Staff S did not remove Staff H from the schedule to prevent her from caring for patients after allegations of physical and emotional abuse.

During a telephone interview on 01/27/16 at 8:30 AM, Staff H, PCT, stated that:
- She placed a squeaky dog toy in the patient's mouth to prevent her from biting herself or staff.
- She was not informed that she would only be allowed to work with direct supervision following the incident.
- She was assigned patients and did not have a change in her assignment or a decrease in duties following the incident.
- She worked on the Medical Surgical (Med/Surg) unit as a 1:1 sitter (staff who were assigned to one patient and were to remain with the patient at all times) on Wednesday (11/25/15) and worked on Geri Psych on Thursday (11/26/15).

During an interview on 01/25/16 at 2:41 PM, Staff A, Quality Risk Manager, stated that:
- She learned of the incident on Monday (11/23/15) morning when she read the incident report.
- She felt it (the squeaky dog toy placed in the patient's mouth) was inappropriate CPI technique (CPI, non-violent interventions.)
- She did not think it was abuse because there was no willful intent to cause harm.
- Staff H worked two or three days that week following the incident.

The Quality Risk Manager failed to recognize the physical and emotional abuse of the patient.

During a telephone interview on 01/26/16 at 12:55 PM, Staff U, RN, stated that she was the charge nurse on Med/Surg on Wednesday (11/25/15) night and Staff H was a 1:1 sitter with a patient. She stated that she was not told that Staff H was not to do patient care and was to work with direct supervision.

4. Record review of the facility Timecard dated, 11/22/2015 - 11/28/2015, showed Staff H:
- Clocked in on 11/21/15 at 6:58 PM and clocked out on 11/22/15 at 7:13 AM on date of incident.
- Clocked in on 11/25/15 at 6:57 PM and clocked out on 11/26/15 at 7:07 AM.
- Clocked in on 11/26/15 at 6:59 PM and clocked out on 11/27/15 at 7:10 AM.

During an interview on 01/26/16 at 3:40 PM, Staff B, Chief Executive Officer, (CEO), stated that he remembered that Staff C, Director of Geri Psych, had informed him that Staff H, PCT, was not doing patient care after the incident but that she had worked as a patient sitter.

The CEO failed to recognize that Staff H should have been removed from patient care due to allegations of physical and emotional abuse.














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Based on observation, interview, record review, and policy review, the facility failed to prevent abuse of one of one psychiatric patient (#9) on the Geriatric Psychiatric unit (Geri Psych unit used to treat psychiatric illnesses in the elderly) when a staff member (H) placed a squeaky dog toy in the patient's mouth to prevent her from biting. The facility failed to recognize this incident as abuse. These failures had the potential to place all patients admitted to the facility at risk for their safety from abuse. The facility census was nine.

Findings included:

1. Record review of the facility policy titled, "Allegations of Abuse or Neglect" revised 03/2015 showed:
-PURPOSE: To provide procedures for reporting, investigating, and following-up when an allegation of patient abuse or neglect is made, or when other information is received indicating that patient abuse or neglect may have occurred.
- To provide procedures for providing notice of allegations or investigations and investigation findings to external agencies, as required.
-All patients have the right to be free from abuse or neglect as well as the fear of being abused or neglected.
-Allegations or information indicating that abuse or neglect may have occurred will be thoroughly and promptly investigated with appropriate follow-up action taken.
-All Hospital employees have an obligation to protect patients, prevent abuse or neglect from occurring, and report any and all information concerning occurrences where abuse or neglect may have occurred.
EMPLOYEE RESPONSIBILITIES AND INITIAL NOTIFICATION PROCEDURES
-Employees who witness or have knowledge of patient abuse shall immediately report it to the Administrator/CEO/President.
-The Hospital Administrator/CEO/President or designee is to be informed immediately when information arises to indicate that patient abuse may have occurred. This may be done directly by any employee when they see or otherwise learn of a situation that constitutes abuse or neglect, or it may be done by the supervisor (e.g. registered nurse on the unit) who received the report from the employee. When the Hospital Administrator/CEO/President cannot be reached, a message is to be left on his/her voice mail and Group Vice President is to be contacted.
REVIEW AND INVESTIGATION
- The investigation process begins when a Nursing Supervisor, the Director of Nursing, the Hospital Administrator/CEO/President or the Medical Director receives information that abuse or neglect may have taken place
- The receipt of information triggers a process for taking action to protect patients and employees, and or collect information to determine facts that will either substantiate a finding that abuse or neglect took place or lead to the conclusion that it did not. In all cases, the emphasis is on finding facts and taking appropriate action to protect all parties, including people who may be victims of abuse and neglect and people who may be unfairly accused.
DEFINITIONS
Abuse:
- The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish or mental illness.
Types of Abuse:
- Physical: An act that results, or has the potential to result in death, pain, temporary or permanent disfigurement, or impairment of any bodily organ or function. Examples include, but are not limited to rough handling, hitting, slapping, pinching, pushing, shoving, kicking, and controlling behavior through corporal punishment.
- Emotional or psychological: An act which results, or has the potential to result in mental impairment of a patient's intellectual or psychological functioning. Examples include, but are not limited to humiliation, harassment, imitating or mocking behavior, inappropriate threats of punishment or deprivation, use of derogatory nicknames.

2. Record review of Patient #9's medical record showed in the Discharge Summary the patient was an elderly female who was admitted to the facility on 11/20/15 for worsening dementia (memory loss) with increased aggression. She was pacing, had high anxiety, cried easily and was confused.

3. During an interview on 01/25/16 at 2:30 PM, Staff C, Director of Geri Psych, stated that:
- She learned Monday (11/23/15) morning that Staff H, Patient Care Tech (PCT), had placed a squeaky dog toy (a dog toy which was used by the unit as a call light and looked like a tree branch that was approximately seven and a quarter inches long and was graduated in length from one and a quarter inches to one half inches wide which emitted a squeaky noise when squeezed) into a patients mouth to prevent the patient from biting while being dressed.
-This had happened in the early morning hours of the Saturday night shift (11/22/15) and she learned of it because the staff was upset because Staff H was joking about the incident.
- Staff H worked the rest of the week but couldn't work alone or without the supervision of another staff.
- She examined the patient's mouth for injury but did not document the examination.
- The patient's physician was aware of the incident on Monday during a treatment team meeting.

4. Record review of the undated facility document titled, "Huddle: Nov 23, Nov 24" page 1 showed:
- Incident occurred over the week-end, this is a reminder to all staff not to insert items into patient's mouth!
- Page 2 showed:
- Staff C also came in on the 28th, spoke with week-end staff (not to insert items into patient's mouth)
No staff sign in sheets were provided with this documentation. No further education was provided to staff.

5. Record review of the facility Timecard dated, 11/22/2015 - 11/28/2015, showed Staff H:
- Clocked in on 11/21/15 at 6:58 PM and clocked out on 11/22/15 at 7:13 AM on date of incident.
- Clocked in on 11/25/15 at 6:57 PM and clocked out on 11/26/15 at 7:07 AM.
- Clocked in on 11/26/15 at 6:59 PM and clocked out on 11/27/15 at 7:10 AM.

During an interview on 01/25/16 at 2:41 PM, Staff A, Quality Risk Manager, stated that:
- She learned of the incident on Monday (11/23/15) morning when she read the incident report
- She received written statements from the Registered Nurse (RN) and PCT on Tuesday or Wednesday.
- She felt it (the squeaky dog toy placed in the patient's mouth) was inappropriate Crisis Prevention Institute (CPI, non-violent interventions) technique.
- Staff H was trying to protect herself which would be a persons' first response.
- The patient spit the toy out.
- The toy wasn't in her mouth very long.
- We did not think it was abuse because there was no willful intent to cause harm.

During an interview on 01/26/16 at 7:08 AM, Staff I, PCT, stated that:
- The patient came out into the hallway and asked to be dressed.
- She walked with the patient into the patients' room where Staff H, PCT, was getting the hygiene kit (items such as deodorant, tooth brush etc).
-The patient had been cooperative but suddenly grabbed her hoody (sweatshirt with hood) and began kicking, hitting and trying to bite.
- Staff J, RN, entered the room and held one arm of the patient and Staff H held the other arm of the patient while she attempted to put the shirt on over the patient's head.
- Staff H then tried to guide the patient's arm through the sleeve while the patient was kicking and trying to bite.
- Staff H put the squeaky dog toy in the patient's mouth and they completed dressing the patient and the patient spit the squeaky toy out of her mouth.
- She stated that she did not report this incident because it had been witnessed by her supervisor, Staff J, RN, and she expected him to report it.

During an interview on 01/26/16 at 8:10 AM, Staff D, Chief Operating Officer/Chief Nursing Officer (COO/CNO), stated that he was told by Staff A, on 11/23/15 that a PCT had put a squeaky dog toy into the patient's mouth. He stated that he was out on sick leave from 11/24/16 until 01/04/16 and he was not involved in the investigation.

During an interview on 01/26/16 at 8:45 AM, Staff Q, Director of Surgical Services, stated that he was acting as the House Supervisor on 11/23/15 and heard of the incident "through the grapevine". He stated that he did not view it as abuse but as inappropriate CPI. The incident was reported to administration by the Unit Manager prior to his knowledge.

During a telephone interview on 01/26/16 at 9:55 AM, Staff J, RN, Charge Nurse, stated that:
- The patient was in the hallway without her walker and Staff I walked the patient back to her room.
- He heard yelling and went to the room where Staff H and Staff I were with the patient.
- The patient had grabbed Staff I's hoody and that he said her name and offered her his hands which she took.
- The patient was kicking and trying to bite.
- Staff H put the squeaky dog toy in the patients mouth.
- He did not consider putting the squeaky dog toy in the patient's mouth abuse.
- Staff J stated that CPI training taught staff to block and move and
- CPI did not teach staff to put something in the patient's mouth to prevent them from biting.
- Staff J was responsible for educating staff in CPI.
- Staff J did not report this incident to the night House Supervisor.

The Charge Nurse failed to recognize the placing of this dog toy into the patient's mouth was a form of physical abuse and as the person in charge he failed to remove Staff H from patient care.

During an interview on 01/26/16 at 2:00 PM, Staff F, RN, stated that:
- She worked as the day shift charge nurse on 11/22/15 and was told of the incident by Staff V, a day shift PCT.
- Staff V reported that the patient was biting, spitting, kicking, hitting, and screaming when staff tried to dress the patient.
- Staff V stated that Staff H, PCT, stated "I almost pissed my pants. I was laughing so hard every time she tried to bite, the toy would squeak."
- Staff F called the House Supervisor to the unit and told her of the incident.
- Staff V's written statement was placed under the unit Directors office door and she made a copy for herself and the PCT.
- If a patient was upset staff were educated to back away and allow the patient to calm down.
Staff H humiliated the patient by laughing when the patient bit down on the squeaky toy.

During a telephone interview on 01/26/16 at 4:00 PM, Staff S, RN, stated that:
- She was acting as the day House Supervisor on 11/22/15 and was called to the Geri Psych unit.
- She was told by dayshift PCT, Staff V, that a nightshift PCT, Staff H, had placed a squeaky dog toy in a patient's mouth.
- She thought the act was degrading to the patient and had she witnessed the incident she would have called management but she heard of it second and third hand.
Staff S did not follow the facility policy to notify the administrator on call.

During a telephone interview on 01/27/16 at 8:30 AM, Staff H, PCT, stated that:
- The patient was biting and kicking.
- She placed the squeaky dog toy in the patient's mouth to prevent her from biting herself or staff.
- The RN was standing next to the patient and knew the squeaky dog toy had been placed in the patient's mouth.
- She didn't intend to harm or embarrass the patient.
- She was not informed that she would only be allowed to work with direct supervision.
- She was assigned patients and did not have a change in her assignment or a decrease in duties.
- She worked on the Medical Surgical (Med/Surg) unit as a 1:1 sitter (staff who are assigned to one patient and to are remain with the patient at all times) on Wednesday (11/25/15) and worked on Geri Psych on Thursday (11/26/15).
- She was suspended on 12/01/15 and later terminated in relation to this incident.

During a telephone interview on 01/26/16 at 12:55 PM, Staff U, RN, stated that she was the Charge Nurse on Med/Surg on Wednesday (11/25/15) night and Staff H was a 1:1 sitter. She stated that she was not told that Staff H was not to do patient care and was to work with direct supervision.

During an interview on 01/26/16 at 2:20 PM, Staff B, CEO, stated that:
- He was not notified of the event until the following day, Monday, 11/23/15.
- Staff D, COO/CNO, Staff Q, Director of Surgical Services, Staff A, Quality Risk Manager, and Staff C, Director of the Geri Psych Unit, completed the investigation and interviews.
-"It was a very tough situation," the patient was violent, biting at staff and the tech was scared and struggled, "grabbing something to prevent the patient from biting."
- He stated that Staff H did not follow CPI training.
- He stated that Staff H did not work following the incident, "as to my knowledge." - He was aware that Staff C had educated only Staff H and the other staff involved not to put objects into patients mouths.
- He did not view the incident as abusive.

During an interview on 01/25/16 at 3:15 PM, Staff B, Chief Executive Officer (CEO) stated that this incident was not reported because, "we didn't see it (putting the squeaky dog toy in the patient's mouth to prevent her from biting) as abuse.

The failure to report showed that Staff B failed to recognize physical and emotional abuse.

6. Record review of the undated facility investigation titled,"Staff H - Summary of Findings" showed:
- On November 22, 2015 Staff H and a co-worker were attempting to dress a patient.
-The patient tried to bite staff.
- Staff H attempted to stop the patient from biting.
- Staff H grabbed the squeaker and placed it in the patient's mouth as the patient continued to try and bite staff.
- The squeaker was removed from the patient's mouth.
- Staff H admitted to putting the squeaker in the patient's mouth.
- She said she had limited options as to what to do so the patient would not harm herself or others.
- Staff did not feel Staff H was trying to be malicious or abusive.
Summary -
Staff H did not make a good decision when she put the squeaker in the patient's mouth.
Human Resources (HR) supports terminating employee based on the findings of the investigation.

During an interview on 01/26/16 at 3:40 PM, Staff B, stated that he had remembered that Staff C, Director of Geri Psych, had informed him that Staff H, PCT, was not doing patient care after the incident but that she had worked as a patient sitter.

During an interview on 01/26/16 at 4:45 PM, Staff B, stated that Staff H worked after the incident, but that she was supervised.

Staff B, CEO, had conflicting information in three separate interviews regarding his knowledge if Staff H continued to work following the incident and if so in what capacity.





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Based on interview and record review the facility failed to ensure that facility staff were educated on restraint first aid techniques for four staff (H, I, J, and K) of four staff personnel files reviewed. This failure could potentially harm or cause death to any patients that required restraints in the facility. The facility census was nine.

Findings included:

1. Record review of the personnel files for Staff H, Patient Care Tech (PCT); Staff I, PCT; Staff J, Registered Nurse; and Staff K, PCT, showed no evidence of first aid education.

2. Record review of the document titled, "First Aid/CPR (cardiopulmonary resuscitation) /AED (Automated External Defibrillator, a device that automatically analyzes the heart rhythm and treats with an electrical therapy if necessary) Program," dated 03/30/11, showed no specific restraint first aid.

During an interview on 01/28/16 at 9:11 AM, Staff A, Quality Risk Manager, stated that the information provided was used for restraint first aid training.

3. Record review of the facility document received by email on 02/01/16 titled, "Nonviolent Crisis Intervention," dated 12/2010, showed on page seven informal hand written notes regarding restraint first aid that were not dated or signed.