HospitalInspections.org

Based on interview, record review, policy review and Digital Video Disc (DVD) recording review the facility
failed to:
- Prevent abuse of one discharged patient (#12) of one eligible adult psychiatric patient on the Geriatric Behavioral Health Unit (BHU) when the patient was physically abused by staff (A0145);
- Immediately remove staff from patient care after leadership staff identified the staff to patient abuse (A0144);
- Complete a physical examination for one discharged patient (#12) of one patient reviewed following the identification of abuse (A0145); and
- Follow their internal policy for reporting of abuse (A0145).
These failures had the potential to place all patients admitted to the facility at risk for their safety from abuse and resulted in the facility's non-compliance with specific requirements found under the Condition of Participation: Patient Rights. The BHU census was 31. The facility census was 265.

Based on interview, record review, policy review and Digital Video Disc (DVD) recording review the facility failed to immediately remove staff (K) from patient care after leadership staff identified abuse to one patient (#12) of one adult psychiatric patient on the Geriatric Behavioral Health Unit (BHU). This failure had the potential to place all patients admitted to the BHU at risk for their safety. The BHU census was 31. The facility census was 265.

Findings included:

1. Record review of the facility's undated policy titled, "Abuse and Neglect, Clinical Assessment and Reporting," showed:
- Any allegation or observed incident of abuse or neglect by employees will be thoroughly investigated and acted on in compliance with the facility's personnel policies and state law;
- Eligible adult: A person 60 years or older who is unable to protect his own interest or adequately perform or obtain services which were necessary to meet his essential human needs; and
- An employee suspected of abuse or neglect will be immediately removed from the department to provide a safe environment for the patient.

2. Record review of the facility's undated policy titled, "Reporting of Allegations of Patient Neglect, Mental, Physical or Sexual Abuse or Assault," showed:
- The purpose of this policy is to ensure the safety of any individual at the facility and to ensure that the Administrator on Call immediately and effectively reports allegations of sexual or physical abuse, neglect or assault to the appropriate authorities and with the facility.
- Immediate means at the time of witnessing conduct or receiving an allegation of conduct that is the subject of this policy.
- Abuse means any intentional action which harms another person. Abuse includes physical and sexual abuse.
- All individuals, including patients, have the right to be free from abuse, neglect and assault.
- Any employee, physician or contract staff who witnesses or receives an allegation of sexual, physical or mental abuse; neglect or assault of any patient or other individual in the facility shall immediately ensure the safety of that individual and shall immediately make contact with the Administrator on Call or designee.

3. Record review of the facility's undated policy titled "Event Reporting," showed:
-Event: A happening, occurrence or "unanticipated/unexpected adverse outcome" that is not part of the routine care of a particular patient or the routine operation of a healthcare entity. It is a deviation from generally accepted practices or processes.
-reporting: All staff members and/or their manager are responsible for ensuring "events" or any type that they witness, become aware of or are involved in are reported through the "Online Event Reporting System" in a timely manner.
-Event is categorized as safety/security and an example is an allegation of abuse or neglect occurring on campus.

4. Record review of Patient #12's medical record showed:
- He was an 88 year old male who was transferred from another acute care facility after he had been transferred there from his nursing home due to agitation and combativeness. He was subsequently transferred and admitted to the Geriatric BHU on 02/28/17;
- He was able to identify himself but was disoriented to place or time; and
- Psychiatric diagnosis of Major Neurocognitive Disorder (used to describe patients with dementia and/or Alzheimer's) with differential of delirium (restlessness, illusions and incoherence of thought and speech seen in dementia).

5. Review of the DVD recording titled with facility name, dated 03/09/17, showed multiple incidents staff K, RN physically abusing the patient. See A 145 for the citation on abuse.

6. Record review of facility provided document titled, "Punch Detail Report," (time card) showed Staff K worked from 7:00 PM on 03/09/17 to 7:30 AM on 03/10/17. This was the next night shift following the incident in the early morning hours on 03/09/17.

7. During a telephone interview on 04/20/17 at 1:07 PM, Staff O, Team Leader (TL) of Two West Geriatric BHU stated that:
- She was the TL for Two West and that TL was equivalent to a nurse manager;
- She had received an email from Staff N, RN, night shift Charge Nurse on the Four West adult BHU that informed her of some concerns that Staff CC, RN had mentioned to her regarding night shift care partners.
- She had never viewed video recordings before so she asked Staff H, TL for Four West to show her the video;
- She and Staff H viewed the video footage together;
- The video recording had "jerky" movements and she wasn't for sure if it was Staff K's movements that were jerky or if it was the video recording;
- She wished Staff K would have engaged Patient #12 in some form of activity as she mainly walked around the nursing station and back again;
- She felt that when Staff K pulled Patient #12's foot out from underneath it was abusive;
- She discussed what was seen on the video with Staff H;
- She called Staff P, Director of BHU and asked him to come and view the video with her;
- Staff P came and viewed the video with her and Staff O, TL Four West Adult BHU on 03/09/17;
- Staff P directed her to come in early the next morning (03/10/17) as Staff K and Staff L both were scheduled to work the night shift that night (03/09/17) so she could have them stay over and view the video with her after their shift was over;
- Staff P also directed her to "start the investigation, as Human Resources would want us to do this before anything else";
- Staff P messaged his supervisor, Chief Nursing Officer on 03/10/17 and that she directed him to report it to Risk Management;
- "It didn't dawn on me that Staff K should not have been allowed to work another shift"; and
- Staff P told her he wasn't sure if it was abuse or not.

Leadership staff was aware of the abuse by Staff K to Patient #12 prior to her next scheduled shift. They did not recognize the potential for further abuse by Staff K when she was allowed to work her next scheduled shift. This placed all of the BHU patients at risk for their safety.

9. During an interview on 04/19/17 at 9:45 AM, Staff DD, Risk Management, stated that:
- She had spoken to Staff P, Director of BHU and Staff O, TL several times during the day on 03/09/17 and neither of them mentioned that they had viewed a video of staff to patient abuse;
- On 03/10/17 at approximately 12:40 PM, Staff P came to her and said that he had been directed by the Chief Nursing Officer (his supervisor) to report to her regarding an incident that had occurred on Two West BHU;
-Staff P informed her that Staff O, TL, had viewed the video recording with Staff K, RN, Staff M, RN, and Staff L, CP;
- Staff P informed her that he and Staff O didn't feel it was anything that needed to be reported;
- Staff O informed her that she had viewed the video with all three staff and that it was just too "awful" to look at again and that at bedtime that night before it had "dawned" on her that maybe she shouldn't have let those staff members work their next scheduled shift on the night of 03/09/17;
- She asked Staff O, TL if when she realized that the staff members that were viewed in the video were working if she came in to monitor them and Staff O replied no she did not because she worked day shift not nights;
- Staff O informed her that she had asked the physician to exam the patient that morning while the physician was on the floor making rounds.

10. Record review of the facility's internal investigation showed that Staff O, TL viewed video recording on 03/09/17. On the same day she called the involved staff members, Staff K, RN, Charge Nurse, Staff M, RN and Staff L, CP in her office to view the video and discuss. Staff O reported that she reported the incident to Staff P, Director BHU on 03/09/17. Involved staff members were allowed to return to duty on the nightshift on 03/09/17 at 7:00 PM. Staff P, Director BHU alerted Risk Management to the incident on 03/10/17. Staff O, TL contacted Risk Manager on 03/10/17 and stated she did not know she was to report abuse incidents to Risk Management until Staff P told her.

Based on interview, record review, policy review and Digital Video Disc (DVD) recording review the facility
failed to:
- Prevent abuse of one discharged patient (#12) of one eligible adult psychiatric patient on the Geriatric Behavioral Health Unit (BHU) when the patient was physically abused by staff;
- Complete a physical examination for one discharged patient (#12) of one patient reviewed following the identification of abuse; and
- Follow their internal policy for reporting of abuse.
These failures placed all patients admitted to the facility at risk for abuse. The BHU census was 31. The facility census was 265.

Findings included:

1. Record review of the facility's undated policy titled, "Abuse and Neglect, Clinical Assessment and Reporting," showed:
- Any allegation or observed incident of abuse or neglect by employees will be thoroughly investigated and acted on in compliance with the facility's personnel policies and state law;
- Eligible adult: A person 60 years or older who is unable to protect his own interest or adequately perform or obtain services which were necessary to meet his essential human needs; and
- An employee suspected of abuse or neglect will be immediately removed from the department to provide a safe environment for the patient.
- Abuse: Includes but is not limited to abuse to an eligible adult, a person 60 years older who is unable to protect his own interest or adequately perform or obtain services which are necessary to meet his essential human needs;
- Abuse or Neglect from within the facility: When a physician, nurse, social worker or other employee of the facility suspects that a patient has been or may be subjected to abuse or neglect by an employee or care provider associated with the facility that person shall immediately report their findings to the charge nurse or department manager.
- The charge nurse or department manager will notify the attending physician, risk management and department manager immediately and as assessment will be done.

2. Record review of Patient #12's medical record showed:
- He was an 88 year old male who was transferred from another acute care facility after he had been transferred there from his nursing home due to agitation and combativeness. He was subsequently transferred and admitted to the Geriatric BHU on 02/28/17;
- He was able to identify himself but was disoriented to place or time; and
- Psychiatric diagnosis of Major Neurocognitive Disorder (used to describe patients with dementia and/or Alzheimer's) with differential of delirium (restlessness, illusions and incoherence of thought and speech seen in dementia).

3. Review of the DVD recording titled with facility name, dated 03/09/17, showed:
- 2:04:23 AM Patient #12 was seated in a Geri chair (a clinical recliner) with the left side of the chair up against the wall of the nursing station. The chair was in a reclined position and Staff M, RN was seated behind nursing station at computer located in the corner behind the patient. Staff K, RN was behind a column and was not in camera view;
- 2:04:41 AM, Staff K, RN reached over nursing station towards Patient #12;
- 2:04:57 AM, Staff K walked around the nursing station and stood in front of the Geri chair;
- 2:05:23 AM, Staff K retrieved a lounge chair from the patient television lounge area and placed it under the footrest of the Geri chair then walked back around nursing station;
- 2:14:02 AM, Staff K reached over nursing station towards Patient #12;
- 2:14:19 AM, Patient #12 attempted to climb over the right side of the Geri chair and Staff K walked around nursing station to the patient;
- 2:14:22 AM, Staff K took Patient #12's right leg and with an upward motion pushed him back into the Geri chair then placed the blanket back on the patient and the patient removed the blanket. Staff K again placed the blanket back on top of the patient and again the patient removed it. This action was repeated six times over the next one minute 30 seconds.
- 2:15:14 AM, Patient #12 kicks the blanket off of his feet and leaned forward in the chair and attempted to hit at Staff K with his right hand. Staff K grabbed his right wrist with her left hand and held it for approximately five seconds. She then pushed the patients' right leg and knee over towards his left leg then repeated the same action after he would attempt to extend his legs;
- 2:15:33 AM, Patient #12 extended his right leg towards the footrest and Staff K grabbed patients right ankle with her right hand and pushed his right leg over on top of his left leg while pushing the patients' right shoulder back with her left hand;
- 2:15:46 AM, Patient #12 took his left hand and rubbed his right wrist;
- 2:16:04 AM, Patient #12 kicked at Staff K and Staff K grabbed his right ankle;
- 2:16:13 AM, Staff K pushed Patient #12's right leg over on top of his left leg'
- 2:16:17 AM, Staff K walked towards the back of the chair and Patient #12 reached out with right arm at Staff K, Staff K grabbed his right wrist and placed her hands on top of his hands and held them on his lap for 18 seconds then Staff K walked back around to the other side of the nursing station.
- 2:17:07 AM Staff M, RN walked around the nursing station and walked approximately six feet from patient down the hallway out of camera view. She did not look towards the patient;
- 2:17:27 AM Patient #12 again attempted to get out of Geri chair with both legs over the right side of the chair;
- 2:17:38 Staff K walked around the nursing station and stood on the right side of Patient #12;
- 2:17:41 Staff K placed her right hand under Patient #12's lower left leg and with her left hand on top of patients' right thigh she attempted to position him back into the chair;
- 2:17:43 Staff K took her left arm and reached down and picked up patients' left leg and then grabbed both of his ankles and lifted his legs up towards the ceiling and pushed him back into the chair. This caused the front wheels of the Geri chair to come off of the floor and the chair tipped backwards. She then positioned both legs down on the footrest of the Geri chair;
- 2:17:53 Staff K walked away, patient rubbed his right ankle and then his left ankle;
- 2:18:39 Patient #12 attempted to crawl over side of Geri chair;
- 2:18:39 Staff K walked around the nursing station back to Patient #12 and stood at the right side of the patient;
- 2:18:47 Staff K picked up Patient #12's ankles and placed them back on the footrest and replaced the blanket on top of the patient. The patient removed the blanket and Staff K replaced the blanket. This action was repeated nine times over the next two minutes;
- 2:20:10 Staff K placed her left hand on Patient #12's right shoulder and pushed him back down into the Geri chair;
- 2:20:18 Staff K took both hands and held patients ankles and placed them back on to the footrest;
- 2:20:19 Staff K positioned the lounge chair back underneath the footrest of the Geri chair;
- 2:20:38 Staff K placed patients' ankles back onto the footrest of the Geri chair;
- 2:20:43 Patient #12 removed his legs/feet from the footrest and Staff K again placed them back on the footrest;
- 2:21:22 Staff K placed patients' right foot back onto the footrest;
- 2:21:29 Staff L, Care Partner, CP, came into camera view and Staff K walked away from camera view; and
- 2:21:37 Staff L, CP, removed the lounge chair from underneath the Geri chair and wheeled the Geri chair with Patient #12 seated in it out of camera view.

Staff K used excessive force multiple times with Patient #12 to reposition him into his Geri chair. Staff K did not recognize that the repeated attempts to cover the patient with the blanket increased his agitation.

4. Record review of facility document titled, "Student and Group Transcript Record," showed the following training for Staff K, RN:
- Restraints on 04/19/16;
- Rapid Regulatory Compliance for Patient Rights, Restraint/Seclusion, and Patient Abuse/Assault/Neglect on 04/21/16; and
- Nursing Service orientation on 05/20/16;

5. Record review of Patient #12's Physician Inpatient Psychiatry Progress note dated 03/09/17 showed that the patient had continued with intermittent agitation/combativeness the previous night and required an injection at 11:37 PM. There was no documentation of physical exam due to alleged abuse.

6. During a telephone interview on 04/19/17 at 9:15 AM, Staff L, Care Partner (CP) stated that:
- She had cared for Patient #12 on several occasions prior to the night of 03/09/17;
- When Patient #12 was restless it usually indicated that he was wet or hungry and if she changed him and/or fed him it usually helped; and
- She had taken Patient #12 into the dining area and fed him some crackers after the alleged incident and he calmed down after that.

7. During a telephone interview on 04/20/17 at 1:07 PM, Staff O, Team Leader (TL) of Two West Geriatric BHU stated that:
- She was the TL for Two West and that TL was equivalent to a nurse manager;
- She had received an email from Staff N, RN, night shift Charge Nurse on Four West adult BHU informing her of some concerns that Staff CC, RN had mentioned to her regarding night shift CP's that were listening to music on their cell phones and that someone should view the video footage to see this;
- She had never viewed video recordings before so she asked Staff H, TL for Four West to show her how;
- She and Staff H viewed the video footage together;
- When she viewed Staff K's actions with Patient #12 on the early morning hours of 03/09/17 she wasn't sure of what she had seen that the video was "jerky" and didn't know if the "jerky movements of the film was due to the film or it was actually Staff K";
- She wished Staff K would have engaged Patient #12 in some form of activity as she mainly walked around the nursing station and back again;
- Staff K pulled Patient #12's foot out from underneath of him and she felt this was abusive;
- She discussed what was seen on the video with Staff H and that Staff O had the same feeling and both were "curious" to if what they had seen was really as "rigid" as it appeared but both felt it was abuse;
- She called Staff P, Director of BHU and asked him to come and view the video with her;
- Staff P came and viewed the video with her and Staff H, TL Four West Adult BHU;
- Staff P directed her to come in early the next morning (03/10/17) as Staff K and Staff L both were scheduled to work the night shift that night (03/09/17) so she could have them stay over and view the video with her after their shift was over;
- Staff P also directed her to "start the investigation, as Human Resources would want us to do this before anything else";
- Staff P messaged his supervisor on 03/10/17 and that his supervisor directed him to report it to Risk Management; and
- It didn't "dawn" on her that Staff K should not have been allowed to work another shift and that Staff P had stated that he wasn't sure if it was abuse or not.

8. During an interview on 04/19/17 at 9:45 AM, Staff DD, Risk Management, stated that:
- She had spoken to Staff P, Director of BHU and Staff O, TL several times during the day on 03/09/17 and neither of them mentioned that they had viewed a video of staff to patient abuse;
- On 03/10/17 at approximately 12:40 PM, Staff P came to her and said that he had been directed by the Chief Nursing Officer (his supervisor) to report to her regarding an incident that had occurred on Two West BHU;
- Staff P informed her that Staff O, TL had viewed the video recording with Staff K, RN, Staff M, RN, and Staff L, CP;
- Staff P informed her that he and Staff O didn't feel it was anything that needed to be reported;
- She then went and talked with Staff O, TL;
- Staff O informed her that she had viewed the video with all three staff and that it was just too "awful" to look at again and that at bedtime that night before it had "dawned" on her that maybe she shouldn't have let those staff members work their next scheduled shift on the night of 03/09/17;
- She asked Staff O, TL if when she realized that the staff members that were viewed in the video were working if she came in to monitor them and Staff O replied that no she worked days not nights.
- Staff O informed her that she had asked the physician to exam the patient that morning while the physician was on the floor making rounds.
Patient #12's medical record showed no evidence that the physician was called or a physical exam was performed to rule out any injury following the incident.

9. During a telephone interview on 04/18/17 at 7:00 PM, Staff CC, RN stated that she had worked with Staff K on several occasions and described her patient care as "heavy handed." She stated that she felt Staff K should not work with elderly patients as she was very "impatient and forceful".

10. Record review of the facility's internal investigation showed that Staff O, TL viewed video recording on 03/09/17. On the same day she called the involved staff members, Staff K, RN, Charge Nurse, Staff M, RN and Staff L, CP in her office to view the video and discuss. Staff O reported that she reported the incident to Staff P, Director BHU on 03/09/17. Involved staff members were allowed to return to duty on the nightshift on 03/09/17 at 7:00 PM. Staff P, Director BHU alerted Risk Management to the incident on 03/10/17. Staff O, TL contacted Risk Manager on 03/10/17 and stated she did not know she was to report abuse incidents to Risk Management until Staff P told her.