HospitalInspections.org

Based on review of video, medical records, facility policies and interview it was determined the hospital failed to protect the patients' rights to be free from physical abuse by staff by failing to ensure patients received care in a safe setting in four (#1, 4,5 and 6) of 7 sampled patients. The hospital failed to ensure patients were free from abuse and retaliation, and potential injury resulting from a staff to patient altercation, that was not assessed or recognized. Refer to tag A0144(Standard), A 0145(Standard). The facility failed to ensure that facility policy was enforced regarding the use of seclusion in 1 (#4) of 7 sampled patients. Refer to A0162 (Standard).

Due to the immediate actions taken by the hospital, the immediate jeopardy for A0115 was removed on 10/30/2023. These actions included: The facility developed a policy to address behavioral health alleged/suspected/ or witnessed abuse. Provided immediate education to all staff on new policy as well as current policies regarding abuse. They provided education on abuse towards patients and appropriate techniques to be used. They expanded the video review by leadership to review those incidents staff considered workplace violence. These items were verified through review of policy, review of staff member signed attestations and 26 staff interviews on 10/30/2023 acknowledging they are aware of the updated policy and the current policies in place.

Based on review of video, medical records, facility policies and interviews the hospital failed to protect the patients' right to be free from physical abuse by staff failing to ensure patients received care in a safe setting in four (#1, #4, and #5, #6) of 7 sampled patients. Failure to immediately remove staff members from patient care put other facility patients at risk for abuse.

Findings included:

1) A review of the medical record for Patient #1, a 15-year-old, reflected he was admitted on 03/20/2023 for possible suicide attempt. Review of nursing documentation on 03/25/2023 at 7:30 PM revealed Patient #1 was removed from the day room for not following directions. He came into hallway and had verbal altercation with Staff A, MHT (Mental Health Technician). Staff attempted to talk him down. He began threatening staff and using inappropriate language. He began throwing his food and entered the nurse's station to hit Staff A, MHT. He had to be held back and placed in seclusion. Security was present. Doctor was notified and order received for seclusion and ETO (emergency treatment order-chemical restraint).

Additional documentation dated 03/27/2023 related to the incident on 03/25/2023, reflected Staff A, MHT threw a container of bleach wipes at Patient #1 aggressively, hitting him on the side of the neck.

A review of Staff A, MHT's payroll time punch on 03/25/2023 reflected she continued to work her shift and was not removed from the premises. Staff A, MHT worked a full shift the next day, 03/26/2023.

During a telephone interview on 10/25/2023 at 1:32 PM, Staff J, former assistant nurse manager stated Staff A, MHT was not sent home, but moved off the unit to work another unit after the event. "The team member was still here with an anger problem that could have been directed to other patients."

On 10/25/2023 at 3:56 PM an interview was conducted with the quality manager and the nurse manager, who confirmed Staff A, MHT was moved to another unit after the incident, and then she was suspended after they watched the video on 03/28/2023. They stated the policy does not say they have to be removed from the building. They can be moved to another unit.

At 4:55 PM on 10/25/2023 a follow up interview was conducted with the quality manager and the nurse manager, who stated that the abuse policy says staff can be moved to another unit and may be suspended for the investigation.

During an interview on 10/26/2023 at 9:14 AM with the Director of Quality and Nurse Manager regarding how they ensure the safety of all the patients after an incident of agression from a staff member, the Director of Quality stated the staff member would be removed from the unit where the event took place to calm down and once, they were calm down enough to be able to work they're not going to go back and work with that individual they would go to another unit.

Review of video evidence from 03/25/2023 at 7:23 PM showed Patient #1 standing in front of the nurses' station. Patient #1 threw candy at Staff A, hitting her on the side of the head. Staff A, Mental Health Technician (MHT) then retaliated by throwing a container of disinfecting wipes at Patient #1 hitting him on the side of the neck.


2) A review of the medical record for Patient #4, a 62-year-old, reflected she was admitted on 09/09/2023 for schizoaffective disorder.

Review of Nursing notes in Patient #4's medical record for dated 09/15/2023 by Staff F, Register Nurse (RN) revealed that Patient #4 husband called and informed Staff F, RN that his wife called him and said that a male staff member hit and kicked Patient #4.

Review of the General Observation Narrative note dated 09/18/2023 at 3:50 AM signed by Staff E, RN in Patient #4's medical record, revealed that it was a late entry performed on 09/14/2023 at 11:45 PM by Staff E, RN, showed Patient #4 was taken to the seclusion room to have a quiet environment and when she came out, she was very angry. There was no evidence in the medical record that less restrictive interventions were attempted.

Review of the facility video (no audio) for 09/14/2023 at 9:44 PM revealed Patient #4 sitting in chair in the hallway. Observed Staff D, MHT walk by Patient #4 and entered a patient room. Upon exiting the room, it appeared Patient #4 said something to Staff D, MHT. He turned and pointed his finger at her face, grabbed Patient #4's left arm and forcefully pulled her out of her chair and walked her down to the seclusion/quiet room.

During an interview on 10/26/2023 at 11:43 AM, Staff G, MHT said that Staff D, MHT grabbed Patient #4 out of the chair and took her to the seclusion room for 45 minutes and when Patient #4 was let out, she was crying.

During an interview on 10/26/2023 at 10:12 AM, Staff F, RN said that Patient #4 husband called her on 09/15/2023 and notified her of the MHT hit and kicked his wife while in seclusion. Staff F, RN stated that she told the husband that she was not there, and it occurred on a previous shift, and she will pass it on to the other shift.

During an interview on 10/26/2023 at 12:49 PM, Staff E, RN revealed that Patient #4 became extremely agitated and was not able to be de-escalated and was sent to the quiet room. Staff E, RN stated that she was on the unit but was not in the area when Patient #4 was taken to the quiet room. Staff E stated Patient #4 was in the seclusion room for approximately 10-15 minutes but not more than 20 minutes.

Review of the facility staffing sheets dated 09/14/2023 through 09/17/2023 revealed that Staff D, MHT worked the night of the event and continued to work 3 days more after the allegations of abuse. Staff D, MHT was suspended on 09/18/2023 pending an investigation.

Review of the policy titled Restraints: violent self-destructive behavior, reviewed 09/2022 revealed "The philosophy of [Facility] Health system I that patients have the right to be free from restraints. The organization uses restraints or seclusion only when it can be clinically justified or when patient behavior threatens the immediate physical safety of the patient, staff or others. Restraints or seclusion are only used when less restrictive interventions are ineffective ... alternative interventions include: 1:1 time with patient, assisting with using the telephone, attempting to identify root cause. . ."


3) A review of the medical record for Patient #5, a 31-year-old, reflected he was admitted on 08/02/2023 for polysubstance abuse and bipolar disorder.

Review of the facility video dated 08/03/2023 at 4:00 PM revealed Patient #5 standing in front of the serving area window in the day room, where Staff B, MHT was observed serving him a cup of coffee. Patient #5 threw the cup of coffee at Staff B, MHT. Staff B, MHT exited the kitchen area and tackled Patient #5, pushing him on top of Patient #6 who was sitting in a chair in front of the table near the doorway. Patient #5 was on top of Patient #6 in her chair for approximately 2 seconds, while Staff B, MHT held Patient #5 down, struggling with him. Patient #6 was knocked from her chair to the ground onto her side. Staff I, MHT pulled Staff B, MHT off Patient #5 into the hallway. Patient #5 fell from the chair Patient #6 was sitting in, to the floor.

A review of Staff B, MHT' s payroll time punch on 08/03/2023 reflected he continued to work his shift and was not removed from the premises. Staff B, MHT also worked a full shifts the next two days 08/04/2023, and 08/05/2023.

An interview was conducted with Staff K, Assistant Nurse Manager on 10/26/2023 at 9:31 AM. Staff K disclosed the event of Patient #5 throwing coffee in Staff B' s face happened over the weekend and Staff B, MHT ran through 2 doors to get to the location where the patient was and tackled him to the floor, knocking Patient #6 out of her chair. Staff B, MHT was removed from the nursing unit and placed on another behavior health unit to finish his shift. Staff K, Assistant Nurse Manager revealed that he did not watch the video of the event until 4 days later and that is when Staff B, MHT was taken off the schedule.



4) A review of the medical record for Patient #6, a 35-year-old, reflected she was admitted on 08/02/2023 for polysubstance abuse and psychosis.

Review of the facility video dated 08/03/2023 at 4:00 PM revealed Patient #5 threw a cup of coffee at Staff B, MHT. Staff B, MHT exited the kitchen area and tackled Patient #5, pushing him on top of Patient #6 who was sitting in a chair in front of the table near the doorway. Patient #5 was on top of Patient #6 in her chair for approximately 2 seconds, while Staff B, MHT held Patient #5 down, struggling with him. Patient #6 was knocked from her chair to the ground onto her side. Patient #6 was in a protective fetal position on the floor on her knees and elbows. Staff I, MHT pulled Staff B, MHT off Patient #5 into the hallway. Patient #5 fell from the chair Patient #6 was sitting in, to the floor.

No evidence was found in Patient #6's medical record reflecting she received an assessment for injuries after the encounter with Staff B, or any documentation reflecting the doctor was notified.

In an interview with Staff G, MHT at 10:20 AM on 10/26/23 she stated that she witnessed Staff B, MHT shove Patient #5 on top of Patient #6, knocking both patients to the ground. Patient #6 was complaining of her arm hurting and Staff G, MHT helped her up. Staff G, MHT stated that she told the nurse, Staff H, RN charge, but doesn't think anyone attended to Patient #6.

On 10/26/2023 at 11:39 AM a telephone interview was conducted with Staff H, RN (registered nurse) charge. Staff H, RN charge stated she reported the incident to the nurse manager. She stated she was in the nurses' station and didn't witness what happened. Staff H, RN charge stated she was not aware Patient #6 was knocked out her chair to the floor, until days later.


5) Review of the policy, Harassment-Free Workplace, revised 6/27/23, revealed . . . Depending on the severity of the allegations, team members may be placed on investigatory suspension or temporarily reassigned to another work area/schedule during the time of the investigation.


Review of the Policy, Coaching/Counseling, revised 7/31/23, revealed . . . Investigatory suspension is not used as a step in the of progressive counseling. An investigatory suspension may be utilized if, in the judgment of management, there are such deficiencies the performance or conduct of a team member, in which patient care, or the safety of patients or team members may be compromised, or serious damage or harm could come to the operations of a department.

Team resources is to approve investigatory suspensions. If an appropriate representative cannot be reached, a supervisor or manager may proceed with a decision to place a team member on investigatory suspension provided the appropriate team resources representative is contacted as soon as possible afterwards.

Review of the policy titled Restraints: violent self-destructive behavior, last reviewed 09/2022, revealed "The philosophy of [Facility] Health system I that patients have the right to be free from restraints. The organization uses restraints or seclusion only when it can be clinically justified or when patient behavior threatens the immediate physical safety of the patient, staff or others. Restraints or seclusion are only used when less restrictive interventions are ineffective ... alternative interventions include: 1:1 time with patient, assisting with using the telephone, attempting to identify root cause..."

Based on review of videos, medical record, facility policies and interviews it was determined that the hospital failed to ensure that patients were free from abuse and harassment for 4 patients (#1, #4, and #5, #6) of 7 sampled.

Findings included:

1) A review of the medical record for Patient #1, a 15-year-old, reflected he was admitted on 03/20/2023 for possible suicide attempt. Review of nursing documentation on 03/25/2023 at 7:30 PM revealed Patient #1 was removed from the day room for not following directions. He came into hallway and had verbal altercation with female MHT (Mental Health Technician). Staff attempted to talk him down. He began threatening staff and using inappropriate language. He began throwing his food at MHT and entered the nurse's station to hit MHT (Staff A). He had to be held back and placed in seclusion. Security was present. Doctor was notified and order received for seclusion and ETO (emergency treatment order-chemical restraint).

Additional documentation dated 03/27/23 related to the incident on 03/25/2023, reflected Staff A, MHT threw a container of bleach wipes at Patient #1 aggressively, hitting him on the side of the neck.

Review of video evidence from 03/25/2023 at 7:23 PM showed Patient #1 standing in front of the nurses' station. Patient #1 threw candy at Staff A, hitting her on the side of the head. Staff A, Mental Health Technician (MHT) then retaliated by throwing a container of disinfecting wipes at Patient #1 hitting him on the side of the neck.


2) A review of the medical record for Patient #4, a 62-year-old, reflected she was admitted on 09/09/2023 for schizoaffective disorder.

Review of Nursing notes in Patient #4's medical record for dated 09/15/2023 by Staff F, Register Nurse (RN) revealed that Patient #4's husband called and informed Staff F, RN that his wife called him and said that a male staff member hit and kicked Patient #4.

Review of the General Observation Narrative note dated 09/18/2023 at 3:50 AM signed by Staff E, RN in Patient #4's medical record, revealed that it was a late entry performed on 09/14/2023 at 11:45 PM by Staff E, RN, showed Patient #4 was taken to the seclusion room to have a quiet environment and when she came out, she was very angry.

Review of the facility video (no audio) for 09/14/2023 at 9:44 PM revealed Patient #4 sitting in chair in the hallway. Observed Staff D, MHT walk by Patient #4 and entered a patient room. Upon exiting the room, it appeared Patient #4 said something to Staff D, MHT. He turned and pointed his finger at her face, grabbed Patient #4's left arm and forcefully pulled her out of her chair and walked her down to the seclusion/ quiet room.

During an interview on 10/26/2023 at 10:12 AM, Staff F, RN said that Patient #4 husband called her on 09/14/2023 and notified her of the MHT hit and kicked his wife while in seclusion. Staff F, RN stated that she told the husband that she was not there, and it occurred on a previous shift, and she will pass it on to the other shift.

During an interview on 10/26/2023 at 11:43 AM, Staff G, MHT said that Staff D, MHT grabbed Patient #4 out of the chair and took her to the seclusion room for 45 minutes and when Patient #4 was let out, she was crying.

3) A review of the medical record for Patient #5, a 31-year-old, reflected he was admitted on 08/02/2023 for polysubstance abuse and bipolar disorder.

Review of the facility video dated 08/03/2023 at 4:00 PM revealed Patient #5 standing in front of the serving area window in the day room, where Staff B, MHT was observed serving him a cup of coffee. Patient #5 threw the cup of coffee at Staff B, MHT. Staff B, MHT exited the kitchen area and tackled Patient #5, pushing him on top of Patient #6 who was sitting in a chair in front of the table near the doorway. Patient #5 was on top of Patient #6 in her chair for approximately 2 seconds, while Staff B, MHT held Patient #5 down, struggling with him. Patient #6 was knocked from her chair to the ground onto her side. Staff I, MHT pulled Staff B, MHT off Patient #5 into the hallway. Patient #5 fell from the chair Patient #6 was sitting in, to the floor.

An interview was conducted with Staff K, Assistant Nurse Manager on 10/26/2023 at 9:31 AM. Staff K disclosed the event of Patient #5 throwing coffee in Staff B's face and Staff B, MHT ran through 2 doors to get to the location where the patient was and tackled him to the floor, knocking Patient #6 out of her chair.


4) A review of the medical record for Patient #6, a 35-year-old, reflected she was admitted on 08/02/2023 for polysubstance abuse and psychosis.

Review of the facility video dated 08/03/2023 at 4:00 PM revealed Patient #5 threw a cup of coffee at Staff B, MHT. Staff B, MHT exited the kitchen area and tackled Patient #5, pushing him on top of Patient #6 who was sitting in a chair in front of the table near the doorway. Patient #5 was on top of Patient #6 in her chair for approximately 2 seconds, while Staff B, MHT held Patient #5 down, struggling with him. Patient #6 was knocked from her chair to the ground onto her side. Patient #6 was in a protective fetal position on the floor on her knees and elbows. Staff I, MHT pulled Staff B, MHT off Patient #5 into the hallway. Patient #5 fell from the chair Patient #6 was sitting in, to the floor.

In an interview with Staff G, MHT at 10:20 AM on 10/26/2023 she stated that she witnessed Staff B, MHT shove Patient #5 on top of Patient #6, knocking both patients to the ground. Patient #6 was complaining of her arm hurting and Staff G, MHT helped her up. Staff G, MHT stated that she told the nurse, Staff H, RN charge, but doesn't think anyone attended to Patient #6.


5) Review of the policy titled Restraints: violent self-destructive behavior, #NCL0031a, reviewed 09/2022 revealed "The philosophy of [Facility] Health system is that patients have the right to be free from restraints. The organization uses restraints or seclusion only when it can be clinically justified or when patient behavior threatens the immediate physical safety of the patient, staff or others. Restraints or seclusion are only used when less restrictive interventions are ineffective ... alternative interventions include: 1:1 time with patient, assisting with using the telephone, attempting to identify root cause... De-escalation preference form."

Based on review of medical records, policies, facility video and interviews the facility failed to ensure that policies were followed regarding restraints or seclusion in 1 (#4) of 7 patients reviewed.

A review of the medical record for Patient #4, a 62-year-old, reflected she was admitted on 09/09/2023 for schizoaffective disorder.

Review of Nursing notes in Patient #4's medical record for dated 09/15/2023 by Staff F, Register Nurse (RN) revealed that Patient #4's husband called and informed Staff F, RN. He stated his wife called him and said that a male staff member hit and kicked Patient #4.

Review of the General Observation Narrative note dated 09/18/2023 at 3:50 AM signed by Staff E, RN in Patient #4's medical record, revealed that it was a late entry performed on 09/14/2023 at 11:45 PM by Staff E, RN, showed Patient #4 was taken to the seclusion room to have a quiet environment and when she came out, she was very angry. There was no evidence in the medical record that less restrictive interventions were attempted.

Review of the facility video (no audio) for 09/14/2023 at 9:44 PM revealed Patient #4 sitting in chair in the hallway. Observed Staff D, MHT walk by Patient #4 and entered a patient room. Upon exiting the room, it appeared Patient #4 said something to Staff D, MHT. He turned and pointed his finger at her face, grabbed Patient #4's left arm and forcefully pulled her out of her chair and walked her down to the seclusion/ quiet room.

During an interview on 10/26/2023 at 10:12 AM, Staff F, RN said that Patient #4 husband called her and notified her of the MHT hit and kicked his wife while in seclusion. Staff F, RN stated that she told the husband that she was not there, and it occurred on a previous shift, and she will pass it on to the other shift.

During an interview on 10/26/2023 at 12:49 PM, Staff E, RN revealed that Patient #4 became extremely agitated and was not able to be de-escalated and was sent to the quiet room. Staff E, RN stated that she was on the unit but was not in the area when Patient #4 was taken to the quiet room. Staff E stated Patient #4 was in the seclusion room for approximately 10-15 minutes but not more than 20 minutes.

During an interview on 10/26/2023 at 11:43 AM, Staff G, MHT said that Staff D, MHT grabbed Patient #4 out of the chair and took her to the seclusion room for 45 minutes and when Patient #4 was let out, she was crying.

Review of the policy titled Restraints: violent self-destructive behavior, #NCL0031a, reviewed 09/2022 revealed "The philosophy of [Facility] Health system I that patients have the right to be free from restraints. The organization uses restraints or seclusion only when it can be clinically justified or when patient behavior threatens the immediate physical safety of the patient, staff or others. Restraints or seclusion are only used when less restrictive interventions are ineffective ... alternative interventions include: 1:1 time with patient, assisting with using the telephone, attempting to identify root cause... De-escalation preference form."

Based on review of video, medical records, facility policies and interview it was determined the facility failed to ensure nursing staff were adequately educated on abuse and abuse allegations, resulting in a delay in investigations, immediate action to protect patients and appropriate disciplinary action that put all the patients in the hospital at risk for abuse in 4 (#1, 4#, #5 and #6) of 5 sampled patient incidents. Refer to tag A0392 (Standard).

Due to the immediate actions taken by the hospital, the immediate jeopardy for A0385 was removed on 10/30/2023. These actions included: The facility developed a policy to address behavioral health alleged/suspected/ or witnessed abuse. Provided immediate education to all staff on new policy as well as current policies regarding abuse. They provided education on abuse towards patients and appropriate techniques to be used. They expanded the video review by leadership to review those incidents staff considered workplace violence. These items were verified through review of policy, attestation documentation and staff interviews on 10/30/2023.

Based on review of video, medical records, facility policies and interviews the hospital failed to ensure all nursing staff were aware of the policy for reporting abuse of patients and that nursing staff and supervisors immediately investigated allegations of abuse, for four (1, 4, 5 and 6) of 5 sampled incidents and that post incident assessments were completed on patients in which abuse had been reported or witnessed in three (4, 5, 6) of 5 sampled incidents.



Findings included:

1) A review of the medical record for Patient #1, a 15-year-old, reflected he was admitted on 03/20/2023 for possible suicide attempt. Review of nursing documentation on 03/25/23 and 03/27/2023 revealed Patient #1 began threatening staff and using inappropriate language. Patient #1 threw candy at Staff A, MHT (mental health technician). Staff A, MHT then threw a container of bleach wipes at Patient #1 aggressively, hitting him on the side of the neck.

Review of video evidence from 03/25/23 at 7:23 PM showed Patient #1 standing in front of the nurses' station. Patient #1 threw candy at Staff A, hitting her on the side of the head. Staff A, Mental Health Technician (MHT) then retaliated by throwing a container of disinfecting wipes at Patient #1 hitting him on the side of the neck. The patient then leaped through the opening of the nurses station to go after Staff A, MHT, who moved back. Patient #1 was physically stopped by the other staff members in the nurses station and taken to the seclusion/isolation room.

During a telephone interview on 10/25/23 at 1:32 PM, Staff J, former assistant nurse manager stated Staff A, MHT was not sent home, but moved off the unit to work another unit after the event. "The team member was still here with an anger problem that could have been directed to other patients."

On 10/25/23 at 3:56 PM an interview was conducted with the quality manager and the nurse manager, who confirmed Staff A, MHT was moved to another unit after the incident, and then she was suspended after they watched the video on 03/28/2023, 3 days later. They stated the policy does not say they have to be removed from the building.


2) A review of the medical record for Patient #4, a 62-year-old, reflected she was admitted on 09/09/2023 for schizoaffective disorder.

Review of Nursing notes in Patient #4's medical record dated 09/15/2023 by Staff F, Register Nurse (RN) revealed that Patient #4's husband called and informed Staff F, RN that his wife called him and said that a male staff member hit and kicked Patient #4.

Review of the General Observation Narrative note dated 09/18/2023 at 3:50 AM in Patient #4's medical record, revealed that it was a late entry for 09/14/2023 at 11:45 PM by Staff E, RN, stating Patient #4 was taken to the seclusion room to have a quiet environment and when she came out, she was very angry.

Review of the facility video (no audio) for 09/14/2023 at 9:44 PM revealed Patient #4 sitting in chair in the hallway. Staff D, MHT walked by Patient #4 and entered a patient room. Upon exiting the room, Patient #4 said something to Staff D, MHT. He turned and pointed his finger at her face, grabbed Patient #4's left arm and forcefully pulled her out of her chair and walked her down to the seclusion/quiet room.

During an interview on 10/26/2023 at 10:12 AM, Staff F, RN said that Patient #4 husband called her and notified her Staff D, MHT hit and kicked his wife while in seclusion. Staff F, RN stated that she told Patient #4's husband that she was not present when it happened. It occurred on a previous shift, and she will pass it on to the next shift. There was no evidence that a physical assessment was completed.


3) A review of the medical record for Patient #5, a 31-year-old, reflected he was admitted on 08/02/2023 for polysubstance abuse and bipolar disorder.

Review of the facility video dated 08/03/2023 at 4:00 PM revealed Patient #5 standing in front of the serving area window in the day room, where Staff B, MHT was observed serving him a cup of coffee. Patient #5 threw the cup of coffee at Staff B, MHT. Staff B, MHT exited the kitchen area and tackled Patient #5, pushing him on top of Patient #6 who was sitting in a chair in front of the table near the doorway. Patient #5 was on top of Patient #6 in her chair for approximately 2 seconds, while Staff B, MHT held Patient #5 down, struggling with him. Patient #6 was knocked from her chair to the ground onto her side. Staff I, MHT pulled Staff B, MHT off Patient #5 into the hallway. Patient #5 fell from the chair Patient #6 was sitting in, to the floor.

An interview was conducted with Staff K, Assistant Nurse Manager on 10/26/2023 at 9:31 AM. Staff K disclosed the event of Patient #5 throwing coffee in Staff B's face happened over the weekend and Staff B, MHT ran through 2 doors to get to the location where the patient was and tackled him to the floor, knocking Patient #6 out of her chair. It happened over the weekend. Staff K, assistant nurse manager, disclosed that he didn't find out about it until Monday. Staff K, Assistant Nurse Manager also admitted that he did not watch the video of the event until 4 days later.

There was no evidence found in Patient #5's medical record reflecting a post incident physical assessment was completed, nor evidence that the doctor was notified.

4) A review of the medical record for Patient #6, a 35-year-old, reflected she was admitted on 08/02/2023 for polysubstance abuse and psychosis.

Review of the facility video dated 08/03/2023 at 4:00 PM revealed Patient #5 threw a cup of coffee at Staff B, MHT. Staff B, MHT exited the kitchen area and tackled Patient #5, pushing him on top of Patient #6 who was sitting in a chair in front of the table near the doorway. Patient #5 was on top of Patient #6 in her chair for approximately 2 seconds, while Staff B, MHT held Patient #5 down, struggling with him. Patient #6 was knocked from her chair to the ground onto her side. Patient #6 was in a protective fetal position on the floor on her knees and elbows. Staff I, MHT pulled Staff B, MHT off Patient #5 into the hallway. Patient #5 fell from the chair Patient #6 was sitting in, to the floor.

No evidence was found in Patient #6's medical record reflecting she received an assessment for injuries after the encounter with Staff B, or any documentation reflecting the doctor was notified.

In an interview with Staff G, MHT at 10:20 AM on 10/26/23 she stated that she witnessed Staff B, MHT shove Patient #5 on top of Patient #6, knocking both patients to the ground. Patient #6 was complaining of her arm hurting and Staff G, MHT helped her up. Staff G, MHT stated that she told the nurse, Staff H, RN charge, but doesn't think anyone attended to Patient #6.

On 10/26/2023 at 11:39 AM a telephone interview was conducted with Staff H, RN (registered nurse) charge. Staff H, RN charge stated she reported the incident to the nurse manager. Staff H, RN charge also stated she was the charge that day, and she had a patient assignment. She was in charge of everybody on her unit. There is an AOD (administrator on duty). Staff H said sometimes the AODs have an assignment. Staff H said she heard a patient was trying to go after the staff. There were no injuries reported to her.

An interview was conducted with the nurse manager at 12:15 PM on 10/26/2023. The nurse manager said Staff H, charge RN (registered nurse) was on duty that weekend. She was assigned to that unit. Staff H, RN charge did have an assignment. The charge nurses do discharges, charting, and treatment team. The assistant nurse manager, Staff K and herself are the on call AOD (administrator on duty) on weekends. The nurse manager said she couldn't recall who was told about the incident. The nurse manager stated that she wasn't aware there was a problem with Staff B, MHT, until they reviewed the video. That's when they told Staff B, MHT he can't work. They thought it was work-place violence. The nurse manager confirmed an assessment was not documented in Patient #6's record. She stated that there wasn't a note reflecting the doctor was notified.


5) Review of the Policy Abuse, Neglect, and Exploitation: Minors and Vulnerable Adults, Last reviewed 10/2022, revealed "Abuse - any willful act or threatened act that causes or is likely to cause significant impairment to a minor or vulnerable adult ' s physical, mental, or emotional health. . . PROCEDURE FOR REPORTING KNOWN or SUSPECTED PATIENT ABUSE, NEGLECT OR EXPLOITATION

Report knowledge of or reasonable cause to suspect abuse, neglect, or exploitation to the patient's nurse and/or provider. Complete an assessment and if symptoms of abuse, neglect or exploitation are found: 1. Notify the attending provider of the assessment findings. . .3. Notify the other departments in addition to Care Coordination as appropriate Child Life, Security and/or Risk Management. . .4. Report suspected abuse, neglect, or exploitation to the Florida Abuse Hotline (1-800-96-ABUSE). . .5. Complete documentation in the patient's Medical Record to include hotline personnel's name, ID # and outcome of the report.

Review of the policy, Harassment-Free Workplace, revised 06/27/2023, revealed. . .Depending on the severity of the allegations, team members may be placed on investigatory suspension or temporarily reassigned to another work area/schedule during the time of the investigation.

Review of the Policy, Coaching/Counseling, revised 07/31/2023, revealed . . .Investigatory suspension is not used as a step in the of progressive counseling. An investigatory suspension may be utilized if, in the judgment of management, there are such deficiencies the performance or conduct of a team member, in which patient care, or the safety of patients or team members may be compromised, or serious damage or harm could come to the operations of a department. Team resources is to approve investigatory suspensions. If an appropriate representative cannot be reached, a supervisor or manager may proceed with a decision to place a team member on investigatory suspension provided the appropriate team resources representative is contacted as soon as possible afterwards.