HospitalInspections.org

Based on interview and observation it was determined the Governing Body failed to have an effective Governing Body based on the discovery of two seperate incidents of patient abuse discovered during a complaint investigation conducted 05-31-12 to 06-04-12. This failed practice had the potential to affect all patients admitted to the hosptial. See A115, A143, A144 and A145.

Based on interviews and observations, it was determined the Facility failed to protect the rights of two (#5 and #8) of fourteen (#1-14) in-patients. Failure to protect patient rights did not allow Patient #5 and #8 to receive care in an environment free from physical abuse, verbal abuse and which protected their right to privacy, dignity and respect. The failed practice affected Patient #5 and Patient #8 and had the potential to affect all patients on 8W. See CMS A-0143, A-0144 and A-0145

Based on review of video recordings provided by the Facility, it was determined the Facility failed to protect the right of personal privacy for 1 (#8) of 14 (#1-14) patients. Failure to protect the personal privacy of Patient #8 did not allow him the basic right of respect and dignity. The failed practice affected Patient #8 on 05/15/12 and had the potential to affect all patients on the 8W Unit. Findings follow:

A. During video review at 1045 on 06/01/12, Patient #8 was seen exiting shower room into hallway at 0657:08. Patient was naked upon exit from shower room and ambulated naked while on every fifteen minute checks behind Mental Health Technician #1 and Registered Nurse #3 while they conferenced in the hallway.

B. The above episode was verified by the Director of Quality at 1125 on 06/01/12.

Based on interview and observations, it was determined the Facility failed to provide care in a safe setting to two (#5 and #8) of fourteen (#1-#14) patients. The Facility failed to ensure Patients #5 and #8 were free from verbal and physical abuse. The failed practice affected Patients #5 and #8 and had the potential to affect all patients on the 8W Unit. Findings follow:

A. During an interview with Patient #12 at 0930 on 05/31/12, an interview with Patient #5 at 1405 on 05/31/12 and Patient #4 at 1430 on 05/31/12, all three patients described an instance of verbal abuse by Registered Nurse #3 (RN) towards Patient #5 in the Day Room. Patients #12, #5 and #4 stated the episode occurred during the current week, RN #3 stated to Patient #5 to grow up and quit living in the past, she had no sympathy for patients who cut their wrists, when you're cutting on yourself you just want attention.

Policy ON015PCS-effective date 6/11-ABUSE AND NEGLECT, SUSPECTED defined the following: Verbal Abuse: means the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to patients or their families or within their hearing distance, regardless of their age, ability to comprehend or disability. Mental Abuse: includes, but is not limited to humiliation, harassment, threats of punishment or deprivation.

Patient #5 was asked how "lady" was rude to him and he responded "She said when you're cutting on yourself you just want attention. She said I had to grow up and quit living in the past. She was rude. She said she had no pity for someone who cuts themselves. We ought to grow up." Patient #5 was asked how he responded to the employee's comments and he stated "I didn't say nothing."

B. Video review revealed MHT (Mental Health Technician) #1 saw Patient #8 behind him and at 0657:33 MHT #1 used both hands and grabbed Patient #8 and shoved Patient #8 into the shower room. The above episode was verified by the Director of Quality at 1125 on 06/01/12.

Based on interview and observations, it was determined the Facility failed to ensure 2 (#5 and #8) of 14 (#1-14) patients were free from all forms of abuse. The Facility failed to ensure Patients #5 and #8 were free from verbal and physical abuse. The failed practice affected Patients #5 and #8 and had the potential to affect all patients on the 8W Unit. Findings follow:

A. During an interview with Patient #12 at 0930 on 05/31/12, an interview with Patient #5 at 1405 on 05/31/12 and Patient #4 at 1430 on 05/31/12, all three patients described an instance of verbal abuse by Registered Nurse #3 (RN) towards Patient #5 in the Day Room. Patients #12, #5 and #4 stated the episode occurred during the current week, RN #3 stated to Patient #5 to grow up and quit living in the past, she had no sympathy for patients who cut their wrists, when you're cutting on yourself you just want attention.

Policy ON015PCS-effective date 6/11-ABUSE AND NEGLECT, SUSPECTED defined the following: Verbal Abuse: means the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to patients or their families or within their hearing distance, regardless of their age, ability to comprehend or disability. Mental Abuse: includes, but is not limited to humiliation, harassment, threats of punishment or deprivation.

Patient #5 was asked how "lady" was rude to him and he responded "She said when you're cutting on yourself you just want attention. She said I had to grow up and quit living in the past. She was rude. She said she had no pity for someone who cuts themselves. We ought to grow up." Patient #5 was asked how he responded to the employee's comments and he stated "I didn't say nothing."

B. Video review revealed MHT (Mental Health Technician) #1 saw Patient #8 behind him and at 0657:33 MHT #1 used both hands and grabbed Patient #8 and shoved Patient #8 into the shower room. The above episode was verified by the Director of Quality at 1125 on 06/01/12.