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Based on interview and record review, the hospital failed to ensure that 2 of 4 current patients (#1 and #2) and 1 of 2 discharged patients (#3) with allegations of staff abuse, were provided with timely and through investigations with responses. The facility also failed to assist 1 patient (#3) in exercising the right to file an abuse complaint increasing the risk of abuse for all patients. Findings include:

Policy:

"Abuse and Neglect," effective 9/30/12, states:

"Any employee that observes, suspects, or is informed of an allegation of abuse/neglect shall make immediate verbal notification to their immediate supervisor (or if unavailable, the Central Nursing Office."

"All allegations of patient abuse and neglect shall be investigated per the Michigan Mental Health Code:"
--R330.7035 requires: "Prompt and through review of charges of abuse."
--330.1724 (1) "In addition to the rights, benefits, and privileges guaranteed by other provisions of law, the sate constitution of 196, and the constitution of the United States, a recipient of mental health services shall have the rights guaranteed by this chapter unless otherwise restricted by law."

Safety Director/Officer on Duty: " initiates telephone contact with law enforcement agency for any patient /guardian who wishes to file a police complaint for any type of assault."

Physician: "Examines the patient thoroughly...documents and fully describes any injuries...examines the patient for external injuries..." (The physician has no role in the investigation.)

Patient #2: video review on 2/27/13 and 2/28/13 revealed:

1. Video evidence shows patient #2 being pushed against a wall by and held by the neck by Mental Health Assistant (MHA) #3.
2. Video evidence shows 3 staff (MHA #4 and 5 and Nurse #4) observing the above events.
3. Video evidence was verified by the Risk Manager during viewing's on 2/27/13 and 2/28/13.

Record Review:

1. On 2/12/13 the Michigan State Police investigated an abuse complaint filed by patient #2's family member, alleging physical abuse by MHA #3 on 1/26/13. Review of this record was verified by the Safety Director on 2/27/13.
2. On 2/13/13 the Acting Director of Nursing sent a memo stating: "While viewing video of the 1/26/13 incident it appears that (MHA #3) is choking the patient (#2), there are 3 staff looking on and that intervened to stop the RCA (MHA #3) and separate her and the patient. This incident was not reported by any staff." The memo recommended suspension of the 3 staff observers for failure to report. (The only staff member who was suspended at the time of the incident was MHA #3.) This memo was verified with the Risk Manager on 2/27/13.

Interviews:

1. On 2/27/13 Recipient Rights Officer #1 stated that the Rights Office is responsible for investigating allegations of patient abuse by staff.
2. According to the Recipient Rights Complaint Log, patient #2 filed complaint alleging abuse, on 2/7/13. That investigation was not completed and available for review on 2/27/13. These reviews were verified by Recipient Rights Officer #1 on 2/27/13.
3. On 2/27/13 the Director of Nursing stated that a hospital -wide training on abuse reporting requirements was not done following the 2/13/13 discovery of 3 staff failing to report possible abuse.

Patient #1:record review 2/27/13-2/28/13 revealed:

1. On 12/28/12 an e-mail to Recipient Rights Advisor #1, the facility Director, the Director of Nursing and the Medical Director, contained the statement that: "(patient #1) stated the staff "jumped on him" and documented the finding (on 2/28/13 by Annapolis Hospital) of 2 fractured ribs.
2. Staff involved in the incident (Nurse #2 and MHA #1) were suspended immediately.
3. The Office of Recipient Rights, responsible for investigating the incident, did not acknowledge receipt of the complaint until 1/2/13, per the "Summary Report." Thus their investigation started 4 days after the Rights Office received notice of patient #1's abuse allegation.
4. The "Summary Report" regarding the investigation and recommending discipline and training was not completed until 1/18/13, 23 days after the incident.
5. In a letter dated 2/22/13, the Hospital Director's "summary report" regarding this incident stated: RCA (MHA) #1: "will be referred for remedial physical management and restraint training."
6. Review of MHA #1's training record revealed that no post-incident training was provided.
7. The above reviews were verified by the Quality Improvement/Utilization Review Coordinator on 2/28/13.


Patient #3's record review on 2/28/13 revealed:

1. On 1/31/12 at 4:45 pm MHA #6 completed an Incident Report stating that "her (patient #3's) forehead hit the ledge of the doorway" during a struggle over smoking materials. The report states that this occurred in the patient's room. "No injury" to the patient was documented on this (4:45 pm) Incident Report.
2. Video review of this incident, with the Risk Manager on 2/28/13, did not show the patient's head hitting the doorway. There are no cameras in patient rooms, where the incident occurred.
3. On 1/31/12 at 7 pm an Incident Report by Nurse #6 states that the patient's: "brother called unit and report his sister had been attacked by staff." This Incident Report documents an injury to patient #3's right forehead.
4. MHA #6 was suspended upon receipt of the abuse allegation.
5. On 1/31/13 at 8:30 pm Safety Officer #1 took photos of the patient #3's forehead and documented "two bumps on the right forehead" and noted that the patient "claimed that she received the injuries from a staff." There was no documentation that the patient was asked if she wished to file criminal charges.
6. On 2/1/13 at 9:35 am Psychiatrist #1, who did not witness the 1/31/12 incident, documented: "Pt. (patient #1) was seen for her incident yesterday...Pt. also reported that she was hit on her head by staff...Pt. says that she wants to tell the truth about the incidents. Pt. is deliberately telling lies on staff at this time. Pt. has very limited insight and (unreadable) into her problems of smoking and telling lies/false allegations on staff. Pt. advised to stay away from trouble at this time."
7. Nothing in the above note explained what investigation or evidence led Psychiatrist #1 to conclude that patient #1 was lying. The investigation was not completed at this time.
8. On 2/1/13 at 9:35 am Social Worker #1 quoted (Patient #3) as saying: "she (unnamed staff member) attached me...I want to press charges." SW #1's note states: "the nursing staff will be advised of her request to press criminal charges against the staff for assault...Patient was also informed that the staff could press charges against her."
8. On 2/21/13 Recipient Rights Advisor #2 sent an e-mail in regard to this investigation stating: "I completed the investigation... There is not a preponderance of evidence to substantiate a violation of Abuse class II by (MHA #6)."

Interviews:

1. On 2/27/13 the Safety Director (SD) stated that the Safety Department did not have documentation of being informed of patient #3's desire to file legal charges against a staff member. The SD stated that all patients have the right to file a criminal assault allegations with the police and that the Safety Department makes the referral when informed of patient requests to file charges.
2. Psychiatrist #1's statements concluding that patient #'s abuse allegation was false was reviewed with the Medical Director on 2/28/13 at approximately 4:30 pm.

Conclusion:

The hospital failed to ensure that 2 of 4 current patients (#1 and #2) and 1 of 2 discharged patients (#3) with allegations of staff abuse, were provided with timely and through investigations with responses. The facility also failed to assist 1 patient (#3) in exercising the right to file an abuse complaint.

Based on interview and record review the facility failed to ensure that:
-- 1 of 1 current patients (#1) received safe application of physical restraints and that staff were re-trained after discovering unsafe restraint application;
--31 of 229 Nurses and Resident Care Aides had current verification of NAPPI (Non-Abusive Psychological & Physical Intervention) training in effect on 2/28/13, resulting in increased risk of injury for all patients during physical restraint. Findings include:

Policy:

"Use of Seclusion and Restraint," #10.7.1, dated 10/25/12, states:

E. "Prone immobilization of a patient for the purpose of behavior control is prohibited unless implementation of other manual methods of restraint other than prone immobilization is medically contraindicated and documented int the patient's record."
L. "The use of restraint or seclusion must be:"
2. "Implemented in accordance with safe and appropriate restraint or seclusion techniques."

A memo from NAPPI International, dated 2/28/13, states: "...if the disciplinary action was due to a staff member's lack of NAPPI skills, we would recommend her/him repeating the initial training and evaluation." (This is an 8-16 hour class.)

Record review for Patient #1:

From 2/27/13-2/28/13 review of patient #1's clinical record and video evidence revealed the following:

1. On 12/28/12 patient #1, a 67 year old male, was lifted and physically restrained in prone position by Nurse #1, based on video review, verified by the Risk Manager.
2. A report dated 12/28/13 states: "Annapolis Hospital reports that (patient) has 2 fractured ribs."
3. An incident report by Recipient Rights Advisor #2, dated 1/18/13, states: "The video showed (Nurse #2) lift (patient #1) up and place him on the floor in the prone position. (Nurse #2) then got on top of (patient #1).
4. In a letter dated 2/22/13, the Hospital Director's "summary report" regarding this incident lists the following requirements:
- (RCA /MHA) #1: "will be referred for remedial physical management and restraint training."
-(Nurse #2) "received a 1-day suspension"...There was no stated training requirement.
5. Review of MHA #1's training record revealed that no post-incident training was provided as required..
6. On 2/22/13 Nurse #1 received training in "Abuse-Neglect Definitions/Reporting" Class hours were not documented.

Interview:
On 2/28/13 at 9:30 am Nurse #1, a NAPPI (Non-Abusive Psychological & Physical Intervention) instructor made the following statements:

1. That use of "prone (physical) restraint is not an approved NAPPI technique."
2. MHA #1 did not receive physical restraint training after this incident.
3. "I provided NAPPI training to Nurse #1 on 2/22/13." The session lasted 1.5 hours, per Nurse #1's statement.
4. When asked if 1.5 hours satisfied NAPPI Standards for retraining in this situation, Nurse #1 stated that it did not, that the "full initial training" should have been repeated. Nurse #1 stated that the schedule on 2/22/13 did not allow for more than 1.5 hours of training on that day.


Policy:

"Use of Seclusion and Restraint," #10.7.1, dated 10/25/12, states:

34.) Training Department: "Provides new employee orientation and annual training on NAPPI and WRPH (Walter Reuther Psychiatric Hospital) SOP 217 on the use of seclusion /restraint to all direct, non-direct, and in-direct care employees."
35.) Hospital Director/Designee: "Ensures employees receive training in the safe use of seclusion/restraint."

Interviews:

1. On 2/28/13 at 9:30 am Nurse #1, a certified NAPPI ((Non-Abusive Psychological & Physical Intervention) Instructor, was asked how the facility monitors to ensure that staff maintain current certification. Nurse #1 stated that she did not know.
2. On 2/28/13 at approximately 10:30 am Nurse Educator #1 was asked for records documenting that all nurses and Mental Health Assistants were current in NAPPI training. NM #1 was unable to state who was responsible for monitoring this process.

Record Review:

On 2/28/13 at approximately 5 pm record review revealed that :

1. 30 of 229 nurses or MHA's were "past due" in completing NAPPI training, per a document provided by the Training Department, titled NAPPI Training (Nursing Staff only).
2. Per policy (above) all staff are required to be trained initially and annually.

Conclusion:

The facility failed to ensure that:
-- 1 of 1 current patients (#1) received safe application of physical restraints.
-- That staff were re-trained after discovering unsafe restraint application.
-- Only 31 of 229 Nurses and Resident Care Aides had current verification of NAPPI training in effect on 2/28/13.