HospitalInspections.org

Based on interviews and medical record review,
the hospital failed to treat an allegation of physical
abuse against Patient Identifier (PI ) # 1, as a
grievance. As a result, PI # 1 and /or PI # 1's
family failed to receive written notification of the
result of the hospital's complaint investigation.
This deficient practice affected PI # 1, one of ten
sampled patients.

Findings Include:

PI # 1 was admitted to the hospital on 6/30/2011 with diagnoses to include Psychotic Disorder not otherwise Specified and History of Autism.

According to the History and Physical (H&P) dated 7/5/2011, PI # 1 had become increasingly agitated and was hearing voices telling him to kill himself for several days prior to admission. PI # 1 also threatened to harm his family.

The Mental Status Examination portion of the H&P documents PI # 1 was alert, calm, very childlike and immature. PI # 1 was oriented to person and time only, he could not identify the place or the reason for admission. PI # 1's associations were loose and he endorsed command type hallucinations. PI # 1's thought processes were ruminative and he appeared delusional. PI # 1's attention and concentration were poor, his posture was slumped and he demonstrated a shuffling type gait.

During an in interview on 8/31/2011 at 2:10 PM,
the complainant states she attended a family
conference at the hospital on 7/8/2011. "I
saw the bruising on his (PI # 1's) elbow. He
(PI # 1) showed me his knee." According to the complainant, PI # 1 said he was shoved by a
"Big, black man with little glasses."

The complainant reports she informed Employee Identifier (EI ) # 1/ Staff RN about the bruising. Allegedly, EI # 1 offered no explanation about the bruising and left the room. The surveyor asked the complainant if Patient Identifier (PI) # 1 identified the alleged perpetrator and she answered no.

According to the complainant, she talked with the "Head Nurse" on 7/8/2011 about PI # 1's bruises. Reportedly, the "Head Nurse" said staff did not know anything about the bruising, but she still needed to interview two more employees. The complainant said she never heard from the "Head Nurse." The surveyor asked the complainant if she was contacted by anyone from the hospital about the complaint. The complainant said, "The Head Nurse called me and said he (PI # 1) had crawled on his knees in the hallway. "I (complainant) said no. He does not crawl on his knees." The complainant denies receipt of any written information from the hospital regarding the complaint.

The complainant says she spoke with the Director of Nursing (EI # 3) who reportedly said the only reason a patient would be put on the floor would be to protect a patient from self harm. The complainant did not recall the date or time of this conversation.

During an interview with a Staff RN/EI #1 on 9/1/2011 at 3:23 PM, the RN described PI # 1's behavior as "bizarre." PI # 1's speech was fragmented and disorganized. According to EI # 1, "Sometimes he (PI # 1) would stand in his room, holding his bible, and yell out. Preaching." The RN denied any knowledge of PI # 1 being shoved and/or hit by staff or another patient. According to the RN, PI # 1's mother and sister reported that PI # 1 was pushed by another patient. The RN says he asked the family to describe the alleged perpetrator. "The only information the family gave was, "It was a black person." Initially, the family said PI # 1 was "pushed" by another patient, then they said it was a staff member. According to the RN, the family showed the nurse the brushing on PI # 1's antecubital area. The RN said he told the Nurse Manager PI # 1's family "had concerns" they wanted to discuss with the manager. The surveyor asked the RN/ EI # 1 if he advised the Nurse Manager about the family's specific allegation that PI # 1 was allegedly pushed by staff or another patient and he said, "No."

During an interview on August 31, 2011 at 3:30
PM, the Nurse Manager/EI # 2 stated on the day
of discharge (7/8/2011), a member of PI # 1's
family complained PI # 1 was "not treated fairly"
because PI # 1's inpatient stay was not long
enough. The family also reported a tote bag
belonging to PI # 1 was missing. According to
the Nurse Manager / EI # 2, she explained
hospitalization is short term. PI # 1's physician determined PI # 1 was stable for discharge and appropriate to return to outpatient therapy.
The manager asked staff to search for the
missing tote, but the tote was not found.
PI # 1's family accepted money as an equitable replacement for the tote. The surveyor asked the
Nurse Manager/EI # 2 if the family reported
any other concerns and she said, "No."

After PI # 1's discharge, a family member called the Nurse Manager/ EI # 2 and said PI # 1 had
"scuffed" areas on his knee and elbow that were
not present on admission. According to the
Manager, the family denied bleeding or scabbing.

During a second interview on 9/1/2011 at 10:20 AM, the Nurse Manager/EI # 2 was asked if she documented the call from PI # 1's family and she said, "No."

According to the Nurse Manager/ EI # 2, a
member of PI # 1's family called after PI # 1 was discharged (date of call unknown) and reported PI # 1 had "scuff" marks on his knee and arm. PI # 1's family said these areas were not related to the bruise on PI # 1's antecubital area. Allegedly, PI # 1 told this family member that a big, black, bald man who wears glasses "jumped" on him (PI # 1). The family member said PI # 1 did not know if the alleged perpetrator was a patient or a staff member. However, the family member reported a name that sounded like the name of a black
male employee. The Nurse Manager/ EI # 2 reports she told the complainant that she would talk to staff and notify the family of the results.

The Nurse Manager/ EI # 2 says she interviewed all of the psychiatric staff and all staff denied any physical altercation with PI # 1. The surveyor asked the manager if she reviewed PI # 1's medical record for skin issues and the manager said, "Yes, but none were found." PI # 1 was not restrained during his hospitalization, nor was there any documentation that PI # 1 was involved in an altercation with another patient.

The Nurse Manager/EI # 2 says she contacted
PI # 1's family and informed the family that
staff had seen PI # 1 crawling on his knees one
night. The Manager says she reviewed PI # 1's
medical record and could not locate any
documentation related to PI # 1 crawling.
The Nurse Manager/ EI # 2 says she asked
to speak to PI # 1, but the family member said
no because he (PI # 1), "Couldn't remember
things." According to the family, PI # 1 depends
on this family member and a sister to answer
questions for him. According to EI # 2 the
family said PI # 1, "Would never do anything
like that." Allegedly, PI # 1 told his family
that a, "Big, black guy who wears glasses
attacked him." The Nurse Manager says she
informed the Director of Nursing (DON)/ EI # 3
about the complaint and asked the DON to call
PI # 1's family. The Nurse Manager says she did
not document her discussions with the
complainant or hospital staff.

The surveyor asked the Nurse Manager/ EI # 2 if this complaint should have been considered a grievance. The manager said, "In retrospect, yes."

During an interview on 9/1/2011 at 3:30 PM, Staff
RN/ EI # 4 said she was at the nursing station
during the 7:00 PM to 7:00 AM shift and heard
voices in the hall. The RN, responding to the
noise, went out to the hall and saw PI # 1 talking
with a male Mental Heath Technician (MHT).
The RN observed PI # 1 on his knees holding on
to the wall. PI # 1 had dropped his bible. The RN
reports she relieved the MHT and helped PI # 1
with his bible. The RN said, "No harm came to
the patient." The incident was not documented in
PI # 1's medical record and the RN/ EI # 4
does not recall the date.

During and interview on 9/1/2011 at 4:45 PM,
the Mental Health Technician/EI # 5 said he did
not have any knowledge of PI # 1 being pushed
or harmed in any way during PI # 1's
hospitalization.

During an interview on 9/1/2011 at 3:00 PM,
PI # 1's Attending Physician / EI # 6 said
PI # 1 had a rash on admission, but the MD
does not recall any bruising. According to the
physician, he has zero tolerance for abuse and
states PI # 1 was not harmed by staff.

During an interview on 9/2/2011 at 5:30 PM, the
Director of Nursing (DON)/ EI # 3 reports he
was informed by the Nurse Manager/ EI # 2 that
PI # 1's family wanted to talk with him. The DON
says he called twice and left messages. When
PI # 1's family called the DON, the family member
asked a hypothetical question, "What would you
do if your staff was abusing patients or
was reported to be abusing patients." The DON
explained the investigative process would be
initiated for both situations. PI # 1's family never
made an allegation of abuse related to PI # 1 to
the DON/ EI # 3. According to the DON,
the family also asked if the police would be
called. The DON explained law enforcement
would not be contacted unless warranted by an investigation. Reportedly, the family said,
"Well, don't you think you should call the police."
The DON described the conversation as
"bizarre." The DON/ EI # 3 said the Nurse
Manager/ EI # 2 did not inform him about the
family's allegation of physical abuse of PI # 1
prior to his conversation with the family.

After the DON/ EI # 3 spoke with PI # 1's family,
he stated the Nurse Manager/ EI # 2 informed
him about the abuse allegation. The Nurse Manager
had already investigated the complaint and found
that PI # 1 has been observed by staff crawling on
his knees on the floor. The DON says he
accepted this as a "valid explanation." When the surveyor asked if this complaint was treated as a grievance, the DON said "no." "Looking back, it should have been."

On 8/31/2011 at 3:45 PM, "Patient Complaints"
for July 2011, documented by the Nurse
Manager/ EI # 2, was reviewed: "(Name of PI # 1).
Discharge July 7. 2011. Mother c/o (complained) that patient was not treated fairly because his stay was not long enough. Tote bag missing- pt's (patient's) mother accepted (dollar amount) for replacement value..."