HospitalInspections.org

Based on record review and interview staff failed to ensure that patients are protected from all forms of abuse including confinement and verbal threats in 1 of 10 records reviewed (Patient (Pt) #1), in total sample of 10 medical records reviewed.

Findings Include:

The facility staff failed to protect and promote patient rights by failing to ensure all patients are protected from abuse including confinement and verbal threats. See tag A-0145

Based on record review and interview staff failed to ensure that patients are protected from all forms of abuse including confinement and verbal threats in 1 of 10 records reviewed (Patient (Pt) #1), in total sample of 10 medical records reviewed.

Findings Include:

Review of policy and procedure titled, "Patient Rights and Responsibilities" last reviewed 12/12/2019 revealed the following:
-Patients have the right to be assured of their reasonable safety while a patient in the hospital, including but not limited to, the right to be free from mental abuse, verbal abuse, and mistreatment.
-Team members will follow current standards of practice...and will protect vulnerable patients...These protections include the patient's emotional health and safety as well as his/her physical safety.

Review of policy and procedure titled, "Behavioral Health Patient and the Emergency Detention..." last revised 03/24/2020 revealed the following:
-Emergency Detention Status: Means the beginning of the Emergency Detention Chapter 51 process, which may lead to a court proceeding called a probable cause hearing, to determine mandatory psychiatric treatment.
-After the patient is seen in the ED (Emergency Department) by the physician or while on an acute care unit, law enforcement is called to place the patient on an Emergency Detention Status, including but not limited to, substantial probability of causing harm to themselves.
-Providers and team members cannot place a patient on, or remove a patient from, an emergency detention status. Law Enforcement is the only entity in the State of Wisconsin who can place a patient on, or remove a patient from an emergency detention status.

Review of Pt #1's medical record revealed Pt #1 was admitted to the inpatient medical surgical unit on 10/21/2022 at 5:54 pm due to an intentional drug overdose; Pt #1 was transferred to a Psychiatric Hospital on 10/22/2022 at 6:40 pm. Per review of Pt #1's History and Physical (H & P) dated 10/21/2022 at 3:53 pm, "Patient is a 31 years old...with a history of bipolar disorder, depression, ADHD (Attention Deficit Hyperactivity Disorder), presents for intentional drug overdose...Earlier today (Pt #1) endorse taking 10 tablets of Xanax (anti-anxiety) 1 mg (milligram) and 5 tablets of Zolpidem (sleeping pill) 10 mg. (Pt #1) claims this was intentional due to (Pt #1) and (Pt #1's) fiance not getting along." Per Pt #1's H & P, Pt #1 was to be admitted for observation, follow-up for behavioral health intake, and 1:1 sitter at bedside.

Review of Physician J's progress note dated 10/21/2022 at 9:18 pm revealed that "(Pt #1) was now chaptered" and "(Pt #1) cannot leave against medical advice"

Review of RN B's progress note dated 10/21/2022 at 10:15 pm revealed, "(Pt #1) attempted to leave room to request new nurse. Writer explained to (Pt #1) that she could not leave room. Racine Officer came to bedside to demand (Pt #1) to sit down on bed. (Pt #1) returned to bed using profanities and stating that she would sue hospital for detaining (Pt #1)."

Per review of Pt #1's complaint/grievance received via "Hotline-Patient Relations" on 10/27/2022 at 11:31 am (during survey), Pt #1 left a voicemail reporting the following, "I was in the hospital Friday-Saturday and was assaulted by a nurse. She pushed me against a wall. I told her not to touch me. She threatened me and said she would do it again...The nurse that watched me overnight Friday (10/21/2022). I wasn't being violent or aggressive, I just wanted to look out into the hallway and she assaulted me.

Per interview with RN B on 10/27/2022 at 2:25 pm, RN B stated that she/he was the primary RN and one to one sitter for Pt #1 on 10/21/2022 to 10/22/2022 from 10:00 pm to 7:30 am. Per RN B, after the Officer read Pt #1 her/his rights (Chapter 51), the Law Enforcement Officer left the room. RN B stated that Pt #1 began demanding to use the phone and RN B told Pt #1 that she/he could not use the phone due to being "Chaptered". Per RN B Pt #1 became agitated and verbally aggressive and attempted to exit the room because Pt #1 wanted to request a different nurse. RN B stated that RN B stood up from the chair and blocked the door way with her/his body and lifted arm (to block the doorway) so Pt #1 could not leave. RN B stated that while RN B was blocking the door way, Pt #1 bumped into RN B's body trying to leave the room. RN B stated that in response to the contact between RN B and Pt #1, Pt #1 stated, "You can't push me!" RN B admitted to responding verbally, "If you thought that was a push, I will do it again." RN B stated that approximately "10 seconds" later the Law Enforcement Officer came back to the room and instructed Pt #1 sit down in the room. RN B stated that she/he was unsure of the protocol when a patient is under Emergency Detention and did not think Pt #1 could use the phone or leave the room. Per RN B, she/he thought the Law Enforcement Officer was supposed to stay in the room to watch the patient. RN B stated that she/he did not complete an incident report in regards to this incident, but stated that she/he probably should have. RN B stated that there were no other witnesses to the incident and that only Pt #1 and RN B were in the room.

Per interview with Security Supervisor H on 10/27/2022 at 3:20 pm, when asked if patients can use a phone to call family while in Emergency Detention (Chapter 51), Supervisor H responded that it would probably be up to nursing staff and the physician if a patient can make phone calls..." Supervisor H than stated that, "Law enforcement would probably make the determination about phone calls, but I'm not sure." Per Supervisor H, Law enforcement is not required to stay in the room with a patient while they are under Emergency Detention, but if the patient elopes, the hospital staff should call law enforcement and let them know the patient has left. Supervisor H stated that Law Enforcement is then responsible for finding the patient and bringing the patient back to the hospital/room. Security Supervisor H stated that hospital staff should not touch a patient and/or physically stop a patient from leaving the room/hospital, staff can verbally try to deescalate and ask the patient to stay..."but we cannot keep them from leaving".

Per interview with Patient Care Manager (PCM) D on 10/27/2022 at 3:35 pm, Manager D stated that staff should never block a patient from leaving the room/hospital, if a patient was under an Emergency Detention and tries to leave, staff should try to verbally deescalate and encourage the patient to stay. Per Manager D, if law enforcement was not present and a patient under Emergency Detention elopes, law enforcement should be called. Per Manager D, RN B should not have blocked Pt #1 from leaving the room. PCM D agreed that it was inappropriate for RN B to say to a patient, "If you thought that was a push, I will do it again."