HospitalInspections.org

The Condition of Participation for Patient Rights has not been met.

Based on clinical record reviews, review of hospital documentation and interviews for one of three sampled Patients (Patient #1) who were reviewed for alleged mistreatment from staff, the facility failed to ensure that the patient was free from physical abuse, failed to ensure timely reporting of a witnessed abuse, and failed to expand reeducation of staff after abuse was substantiated.

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Based on clinical record reviews, review of hospital documentation and interviews for one of three sampled Patients (Patient #1) who were reviewed for alleged mistreatment from staff, the hospital failed to ensure that the patient was free from physical abuse, failed to ensure timely reporting of a witnessed abuse, and failed to expand reeducation of staff after abuse was substantiated. The findings include:

a. Patient #1 was admitted to the hospital on 4/12/2020 with a diagnosis of a urinary tract infection associated with an indwelling urethral catheter. Other diagnoses included COVID-19 infection, neurogenic bladder, spinal cord injury, paraplegia, prediabetes, and a sacral ulcer.

A nurse's progress note dated 4/14/2020 at 8:41 PM identified that RN #2 entered Patient #1's room with water for the patient. Although the water was in a sealed container, Patient #1 said it was contaminated. The patient became angry, refused the water, and refused to have his/her vital signs taken. At that time, it appeared that the patient was recording staff interactions on a personal cell phone. RN #1 left the room to retrieve new water and returned at 8:45 PM. Security Officer #1 was present in the room at that time and witnessed Patient #1 recording on his/her phone.

A Security Incident Report dated 4/14/2020 identified the security office was called at approximately 8:30 PM for assistance with a patient who was video taping staff and other patients. Security Officer #1 arrived on the unit and was told the patient was agitated, aggressive, and disrespectful. Security Officer #1 asked Patient #1 if he/she would delete any recordings of staff or other patients. The patient refused and additional officers were called. The Security Officer then attempted to take Patient #1's phone and when unable to do so, a physical struggle ensued between Security Officer #1 and Patient #1. The cell phone fell to the floor behind the bed. Security Officer #1 left the room with Patient #1's cell phone in hand and then realized that her badge was missing. The Security Officer re-entered the room and Patient #1 threw the hospital phone at her. Security Officer #2 who just arrived was able to block the phone, thus preventing it from hitting the officer. Additionally, the report indicated that Patient #1 threatened to kill the security officers.

A nurse's progress note dated 4/14/2020 at 10:42 PM identified the cell phone was returned to the Patient. The Patient was agitated and initially refused, but later allowed the nurse to conduct an assessment. The Hospitalist was contacted to evaluate the patient.

A Physician Assistant's (PA) progress note dated 4/15/2020 at 12:31 AM identified PA #1 was called to the floor to evaluate Patient #1 who was complaining of pain of the right shoulder, right jaw, right zygomatic arch, and right upper periorbita. The examination identified anterior discomfort of the right shoulder with range of motion, no discoloration of the face, tenderness with no discoloration of the right periorbita, and the neck had full range of motion with no midline tenderness. Patient #1 reported that pain medication was managing his/her discomfort. Imaging of the affected areas was ordered to rule out injury.

A Nurse Practitioner's (NP #1) progress note dated 4/15/2020 at 8:48 AM identified Patient #1 underwent CT scans and no evidence of acute fractures were noted. Patient #1 voiced no complaints of pain during this encounter with the NP.

The hospital's investigation of the incident dated 4/15/2020 was reviewed in the presence of the Director of Patient Relations on 8/14 at 1:30 PM. The Investigation identified that the Nursing Supervisor was notified of the incident and instructed staff to notify the security office. After the incident Security Officer #1 was instructed to leave the hospital. Patient #1's family were then present at the hospital's main entrance. One family member (Person #1), who stated she/he was on face time with Patient #1 during the entire incident indicated that she/he witnessed the physical altercation between the Security Officer and the Patient and had witnessed Security Officer #1 strike the patient in the face and head. The family was able to provide video evidence supporting that Security Officer #2 admitted that Patient #1 was struck in the head by Security Officer #1.

Further review of the hospital's investigation identified that the Nursing Supervisor (RN #1) reported the alleged physical assault to the Patient Relations department via email on 4/15/2020. The hospital initiated the Immediate Response Algorithm that included obtaining statements from the patient, all others involved and two huddles with appropriate hospital managers. The allegation of patient abuse was corroborated by witness statements and recorded evidence of Security Officer #2 admitting to witnessing Security Officer #1 strike Patient #1 and therefore the allegation was substantiated.

Interview on 8/14/2020 at 10:30 AM with the Manager of Security identified that Security Services within the hospital are provided by an outside contracted security company. The Manager indicated that it was inappropriate for Security Officer #1 to attempt to take the patient's personal cell phone, to physically struggle with the patient, and to strike the patient. Crisis Prevention training, which is mandatory for Security officers includes teaching measures to de-escalate situations. The Security officers should not have struggled with the patient and should have left the room to de-escalate the situation.

Security Officer #1's contracted employment was terminated as a result of the incident on 4/14/2020.

Interview with RN #2 and review of RN #2's statement that was provided to the hospital on 8/14/2020 at 11:45 AM identified that he thought Patient #1 was recording his interaction with him/her and staff interaction with his/her roommate. RN #2 asked Patient #1 to stop, and because the patient refused, RN#2 reported the incident to the Supervisor and was instructed to notified security.

Interview with Security Officer #2 and review of Security Officer #2's statement that was provided to the hospital on 8/17/2020 at 11:15 AM identified that Patient #1 was agitated and screaming and was attempting to hit Security Officer #1 with the receiver portion of the hospital phone. He held Patient #1's wrist down to prevent that from happening. Although in his statement to the hospital Security Officer #2 reported that he witnessed the strike, in this interview he indicated that he did not actually see Security Officer #1 strike the patient rather he felt the force of strike. Additionally, Security Officer #2 indicated that he did not report the incident immediately to management because Security Officer #1 was his supervisor. He noted that he should have de-escalated the situation by leaving the room.

Security Officer #2 failed to ensure that an incident of patient abuse was immediately reported.

Interview on 8/20/2020 at 11:00 AM with Person #1 identified that she/he was on face time with Patient #1 while the altercation with Security Officer #1 occurred. She/he witnessed the officer strike Patient #1 on the head with a closed fist.

Interview with Security Officer #1, review of Security Officer #1's statement provided to the hospital and review of the Security Department Report on 8/20/2020 at 12:40 PM identified that during the altercation Patient #1 attempted to pull off her mask and gown while she was attempting to take the patient's phone. The phone then fell to the floor, she picked it up and left the room. Realizing that her badge was missing, she went back into the room to find it. At that time the patient remained agitated and attempted to hit her with the hospital phone. Security Officer #2 appeared and held down Patient #1's hands. Additionally, the Officer indicated that she may have inadvertently hit the Patient on the head during the struggle for the phone. After the incident the Security officer was made aware that it was against hospital policy to remove a patient's person property and the altercation could have been prevented if she left the room and retrieved her badge at a later time.

The Hospital failed to ensure the Patient was free from physical abuse.




b. Interview and review of the Security Department's report on 8/14/2020 at 10:30 AM with the Manager of Security identified that on 4/15/2020 Security Officer #2 was called to the Security Office to discuss the incident that occurred the evening before. At that time, he reported that during the physical altercation between Security Officer #1 and Patient #1 he had witnessed Security Officer #1 strike Patient #1 on the head. Although Security Officer #2 indicated that he was uncomfortable reporting Security Officer #1 who was his immediate supervisor, he should have immediately reported what he had witnessed to the Manager on Duty. On 4/15/2020 Security Officer #2 was provided with re-education on Patient Rights and abuse reporting.

The Hospital failed to ensure a witnessed physical assault was reported immediately to the Manager on Duty.




c. Interview on 8/17/2020 at 11:00 AM with the Director of Regulatory Affairs identified that hospital employees are provided with education on Patient Rights and Abuse Prevention during orientation and every three years thereafter. Although Security Officer # 2 was provided with re-education, the re-education was not extended to other security officers and/or the nursing staff on duty at the time of the incident.


The Hospital's policy on Patient Rights and Responsibilities identifies that as a Patient you have the right to safety and security in an environment that offers dignity, including freedom from neglect or mistreatment.