HospitalInspections.org

Based on interview and record review the facility failed to protect patients from staff and patient abuse and provide a safe environment for care, resulting in increased risk of abuse, injury and criminal charges for all 221 current patients.
Findings include:
--The facility failed to protect 2 of 3 current patients who were physically restrained (patients #13 and #14) from criminal assault charges by staff.
--The facility failed to follow policies for reporting staff injuries and preventing patients from bringing contraband into the facility.
(See A-0144)

--The facility failed to prevent staff with substantiated and pending patient abuse allegations from working with patients.
--The facility failed to investigate abuse allegations in a through, timely manner for 2 of 2 current patients (#5 and #8).
--The facility failed to analyze and respond to 6 incidents of patient abuse (by current patient #7) from 5/3/14-6/5/14.
--The facility failed to develop polices and procedures for reporting and responding to all allegations of patient abuse
(See A-0145)

--The facility failed to modify the treatment plan for 1 of 1 current patients (#14) who was physically restrained during April 2014.
(See A-0166)

Based on record review and interview the facility failed to protect 2 of 3 current patients who were physically restrained (patients #13 and #14) from criminal assault charges by staff and to follow policies for reporting staff injuries and preventing patients from bringing contraband into the facility, resulting in increased risk of assault charges and injury for all 221 current patients. Findings include:

Policy Review:
On 6/24/14 at approximately 1500 review of the following policy was conducted.
Employee Accident and Incident Reporting, dated 7/1/09, states:
5.2 "Written reports of employee work-related injury/illness are to be submitted on the form Department of Community Health (DCH)-1004 (E)..."
5.4 "Supervisors shall immediately investigate all reported injuries/illness to assess the need for immediate correction in the environment, and documents such investigation on form DCH-1005 (E). Supervisor's Investigation Report of employee injury/illness."

Patient #14:
Record Review:
1. On 6/24/14 at approximately 0920 review of patient #14's clinical record and facility "Incident Reports" revealed that the patient was placed in 4-point restraints on 4/2/14 at approximately 0950. Patient #14's Treatment Plan was not updated after this Incident. These findings were confirmed during record review by staff Q on 6/24/14 at 0940.
2. On 6/24/14 at approximately 0920 review of patient #14's clinical record and facility Incident Reports revealed that the patient was restrained in a "Posey net", placed in 4-point restraints on 4/30/14 at 1716. Patient #14 sustained "minor abrasions to both knees" as a result of this incident. This finding was confirmed during record review by staff Q on 6/24/14 at 0950.
3. On 6/24/14 at approximately 1400, review of Security Department communications revealed a 5/1/14 e-mail from staff J to the Security officer (I) stating that staff J was filing a police report against patient #14 as a result of the 4/30/14 restraint incident. Staff J stated, "while placing (patient #14) in restraints she got her arm lose from a staff member and struck me."
4. Review of staff injury reports filed with Human Resources revealed that staff J had not filed an injury report as a result of the alleged injury sustained on 4/30/14.

Interviews
1. On 6/24/14 at approximately 1530 staff J stated that he filed a criminal complaint against patient #14 for hitting him during the 4/30/14 physical restraint incident. Staff J stated that "many staff" participated in physically restraining patient #14 on that date. Staff J stated that the Treatment Team felt that filing criminal charges against the patient might be an appropriate response to the patient's physically aggressive behavior. Staff J stated that this was discussed by the Treatment Team following patient #14's 4/2/14 behavioral episode requiring physical restraint.
2. On 6/24/14 at approximately 1535 patient #14's physician (staff M) was asked if the Treatment Team encouraged staff to file criminal complaints against patient #14. Staff M stated that "this was not the Team's plan (for patient #14)."
3. On 6/14/14 at approximately 1425 Human Resources staff member K was asked whether staff J filed a report regarding injuries sustained in the 4/30/14 restraint incident. Staff K stated that a staff injury report by staff J had not been filed for that incident.

Patient #13:
Policy Review:
On 6/24/14 from approximately 1510 review of the following policy was conducted.
Patient Personal Property, dated 3/29/10, states:
3.1 "An inventory of personal property will be recorded on the Patient Personal Property Receipt at the time a patent is admitted to the hospital, and any time that s/he acquires additional personal property."
3.3 "Only those non-excluded items of personal property considered essential to the patient while at the (facility) may be taken onto the unit."

Record Review:
1. On 6/24/14 at approximately 1340 review of patient #13's clinical record and an Incident Report revealed that the patient was admitted on 6/16/14 and refused to allow staff to search her belongings. Patient #13 was allowed to circulate on the unit without having her belongings inventoried.
2. On 6/24/14 at approximately 1340, a review of a facility Incident Report revealed that during an episode of physical restraints being applied to patient #13 (on 6/19/14) it was discovered that the patient had a safety pin. The report states: "Patient (#13) stated she had the pin since jail." The analysis section of the Incident Report stated only, "Appropriate action by staff."
3. On 6/24/14 at approximately 1400 review of Security Department communications revealed that on 6/20/14 staff N e-mailed the Security Director, informing him that he wished to press charges against patient #13 for stabbing him with a safety pin during the 6/19/14 physical restraint incident.

Interviews:
1. On 6/24/14 at approximately 1400 Security staff (I) stated that patient #13 was allowed to bring her belongings onto the unit without having the property inventoried.
2. On 6/24/14 at approximately 1400 staff I stated that the State Police met with staff N on 6/23/14 to initiate the process of filing charges against patient #13 as a result of the 6/19/14 physical restraint incident.
3. On 6/24/14 at approximately 1415, Staff I stated that the above policy for inventorying the patient's belongings was not followed because it was believed to conflict with other policies.

Based on record review and interview the facility failed to protect 33 current patients on the East-3 Unit from physical abuse by:
--failing to prevent staff with substantiated and pending patient abuse allegations form working with patients
--failing to investigate abuse allegations in a timely manner for 2 of 2 current patients (#5 and #8)
--failing to analyze and respond to 6 incidents of patient abuse (by current patient #7) from 5/3/14-6/5/14
--failing to develop polices and procedures for reporting and responding to all allegations of patient abuse
--increasing the likelihood of patient abuse for all 221 current patients.
Findings include:

Policy Review on 6/24/14 at 1500 revealed the following:
Abuse and Neglect: Reporting, Investigation and Review, dated 7/1/10 states: "It is the policy of (facility) to prohibit acts of commission or omission which are abusive or neglectful of (facility) patients and to assure that all incidents of abuse or neglect are reported, reviewed, and investigated in a timely manner." The facility policy lacks a requirement that staff report all patient complaints of abuse or neglect. The policy failed to define patient to patient assaults as abuse unless they rise to the level of, "criminal abuse." No procedures for responding to non-criminal patient to patient abuse are provided. The policy requires staff to complete Incident Reports at the time abuse or neglect is "witnessed, discovered, or suspected with reasonable cause."

Per policy, the Office of Recipient Rights (ORR) is assigned responsibility, "to conduct a thorough and independent investigation" of abuse and neglect allegations. The policy assigns the "Area Supervisor/Nursing" responsibility for conducting "preliminary investigation of serious injuries, abuse, neglect, and other life-threatening incidents." These statements are to be submitted to the Director of Nursing, not the Recipient Rights Officer, the staff member responsible for conducting the investigation. No timeline for initiating or completing the ORR's investigation is provided. The policy fails to prohibit staff, with substantiated or pending patient abuse allegations from supervising patients.

Patient #7
Policy Review:
On 6/24/14 at approximately 1615 the following policy was reviewed:
Precautions and Special Interventions for At Risk Patients, dated 1/15/10, states:
"It is (facility) policy to ensure the safety of patients and staff by providing special monitoring and/or precautionary measures when a patient demonstrates an increased risk that may not be sufficiently addressed by general patient safety and clinical care practices."
"Treatment Team Staff: Perform formal assessments relevant to risk issues...in response to charges in the patient's condition."

Record Review:
1. On 6/24/14 from 0900-1500 review of May and June 2014 Incident Reports for patient #7 revealed that this patient assaulted other patients on the following dates:
--On 5/3/14- patient #7 pushed patient #9 to the floor. The "Incident Report" (IR) analysis section, for: "Program or administrative action taken, including disciplinary action, to remedy and /or prevent recurrence of incident" stated, "treatment team to be notified." No documentation of team discussion of measures to protect other patients was noted.
--On 5/12/14- patient #7 hit patient #10 on the left side of the face. The only actions taken to prevent recurrence (noted on the IR) were to provide the IR for team review and encourage the patient not to hit people. No documentation of team discussion of measures to protect other patients was noted.
--On 5/19/14- patient #7 "was sitting in the day room, when he got up and walked over to pt. #8 and punched him with a closed fist on the right side of the face." The analysis part of the IR states: "Tx (Treatment) Team will review incident and decide on preventable measures." No follow-up measures to protect other patients from patient #7 were noted.
--On 5/22/14- patient #7 walked out into the unit yard and "walked up to pt (patient) #11 and punched him in his face three times before staff could intervene." The IR analysis section states: "Tx (Treatment) Team will review to remedy preventative measures." No follow-up discussion of measures to protect other patients from patient #7 was noted.
--On 5/25/14- patient #7 "walked out of his room and into the dayroom where he proceeded to strike patient #11 (the same patient he attacked on 5/22/14) in the head and face area with a closed fist. The incident was unprovoked." The analysis section of the IR states: "I refer the incident to the East-3 Treatment Team." No discussion of the Treatment Team discussing measures to protect other patients from patient #7 was noted.
--On 6/5/14- patient #7 entered the library "then began hitting patient #12 in the head." The analysis section of the IR stated, "Staff was directed to monitor patient for further aggressive behavior." Patient #7 was physically restrained and sustained an abrasion to the left forehead. No documentation of the Treatment Team discussing measures to protect other patients was noted.
2. On 6/24/14 at approximately 0935 review of patient #7's record revealed two staff assaults from May 3-June 9, 2014. An Incident Report dated 5/11/14 at 1141 stated that patient #7 hit a staff member "in the back of the head twice" and a "Precaution Monitoring Documentation" sheet dated 6/2/14 at 1000 stated, "(Patient #7) assaulted staff -Placed in Quiet Room."
3. On 6/24/14 at approximately 0945 review of patient #7's record revealed that two "Behavior Management Consult" reports were completed from May-June 2014.
--A 5/14/14 "Behavior Management Consult" note makes no recommendations for protecting other patients or increasing patient #7's supervision level.
--A 5/28/14 "Behavior Management Consult" note recommends that the Treatment Team provide, "further consideration of exposure response prevention." No documentation of the Treatment Team's response to this recommendation was found.
4. On 6/24/14 at approximately 0950 review of patient #7's clinical record revealed that from 5/3/14-6/5/13:
--Patient #7's supervision level was not increased to 1:1 supervision at any time.
--Patient #7's treatment team did not revise the patient's treatment plan during this period.
5. On 6/24/14 at approximately 1000 review of patient #7's current Treatment Plan, dated 6/10/14, revealed the following inaccurate statements:
--"(The patient's) last assault toward staff was on March 8, 2014."
--"Consultation should be made with (patient #7's) treatment team and/or 1:1 staff prior to taking him out of the group room. (The patient does not have orders for 1:1 staff.)

Interviews:
1. On 6/24/14 at approximately 1000 staff E confirmed the following inaccuracies in patient #7's current (6/10/14) Treatment Plan (listed in #5 above).
--Patient #7 last assaulted a staff member on 6/2/14, not 3/8/14. (See #2 above.)
--Patient #7 has not been on 1:1 supervision for groups (or at any time) for several weeks. The consultation protocol (referenced in the current Treatment Plan) is not being done.
2. On 6/24/14 at approximately 1000 staff E stated that there was an increase in patient #7's abusive behavior during May 2014. Staff E confirmed that there was no documentation that the Treatment Team reviewed each of the above Incident Reports for patient #7 from 5/3/14-6/5/14 or of the team responding to the Behavior Management Consult recommendation of 5/24/14. Staff E provided documentation that the Treatment Team had documented unit-wide statements (during May 2014) indicating that no changes in patient supervision were needed but was unable to provide documentation of a formal team assessment in response to the increase in assaults by patient #7.

Patient #8:
Record Review:
1. On 6/24/14 at approximately 0930 review of facility Incident Reports revealed that patient #8 was punched in the face by patient #7 on 5/19/14 (see #1 above).
2. On 6/24/14 at approximately 1515 review of a "Report of Investigative Findings," dated 11/25/13, written by staff O, revealed that the Office of Recipient Rights substantiated an abuse allegation against staff P for encouraging patient #7 to hit patient #8 on 9/30/13. The report includes a second allegation by patient #8, alleging that staff P hit him too.

Interviews:
1. On 6/24/14 at approximately 1515 staff O confirmed that the above complaint was received on the date of the incident (9/30/13) and that the "Report of Investigative Findings" was not completed until 11/25/13. Staff O confirmed that the patient's allegation of being abused by staff P (on 9/30/13) was not ruled on in this report.
2. On 6/24/14 at approximately 1515 staff O stated that staff P is still employed at the facility.
3. On 6/24/14 at approximately 1445 Human Resources staff K confirmed that the facility does not have policies or procedures that prevent staff with substantiated abuse allegations from continuing to work with patients

Patient #5:
Record Review:
1. On 6/24/14 at approximately 0840 review of facility complaint records revealed that patient #5 filed a written complaint on 4/2/14 alleging physical abuse by "staff." Patient #5 was first interviewed in regard to the allegation on 4/4/14, by staff B. The patient identified staff G as the alleged abuser.
2. On 6/24/14 at approximately 0840 review of the Office of Recipient Rights (ORR) complaint file revealed an internal communication from staff B, dated 4/4/14 requesting approval to view video of the hallway at the time of the alleged incident. On 4/8/14 staff B e-mailed the facility Director, stating, "Reviewed the video today there is no need for suspension."
3. On 6/24/14 at approximately 1445 Human Resources staff K stated that staff G was not suspended between the (above) abuse allegation being filed (on 4/2/14) and completion of the video review by staff B (on 4/8/14).
4. On 6/24/14 at approximately review of staff G's personnel file revealed that the staff member had a substantiated finding of patient abuse, for an incident that had occurred on 11/1/12, where patient #15 suffered two broken ribs.
5. On 5/27/14 staff B sent patient #5 a "60 Day Status Report,", regarding this complaint investigation, stating that "the investigation had not been completed."

Interviews:
1. On 6/24/14 at approximately 0845 staff B stated that she has responsibility for investigating patient #5's abuse complaint. Staff B stated that documentation of the complaint investigation, including sending a response letter to the patient, has not been completed.
2. On 6/24/14 at approximately 1445 Human Resources staff K confirmed that the facility does not have policies or procedures that prevent staff, with substantiated abuse allegations from continuing to work with patients and that staff G was not suspended following patient #5's abuse allegation on 4/2/14.

Based on record review and interview the facility failed to modify the treatment plan for 1 of 1 current patients (#14) who was physically restrained during April 2014, resulting in criminal charges being lodged against the patient by staff, increasing the risk criminal complaints for all 221 patients.
Findings include:

Record Review:
1. On 6/24/14 at approximately 0920 review of patient #14's clinical record and facility Incident Reports revealed that the patient was placed in 4-point restraints on 4/2/14 at approximately 0950. Patient #14's Treatment Plan was not updated after this Incident. These findings were confirmed during record review by staff Q on 6/24/14 at 0925.
2. On 6/24/14 at approximately 0920 review of patient #14's clinical record and facility Incident Reports revealed that the patient was restrained in a "Posey net" placed in 4-point restraints on 4/30/14 at 1716. Patient #14 sustained "minor abrasions to both knees" as a result of this incident. This finding was confirmed during record review by staff Q on 6/24/14 at 0925.
3. On 6/24/14 at approximately 1400, review of Security Department communications revealed a 5/1/14 e-mail from staff J to the Security Officer staff (I) stating that staff J was filing a police report against patient #14 as a result of the 4/30/14 restraint incident. Staff J stated, "while placing (patient #14) in restraints she got her arm lose from a staff member and struck me."

Interviews
1. On 6/24/14 at approximately 1530 staff J stated that he filed a criminal complaint against patient #14 for hitting him during the 4/30/14 physical restraint incident. Staff J stated that "many staff" participated in physically restraining patient #14 on that date. Staff J stated that the Treatment Team felt that filing criminal charges against the patient might be an appropriate response to the patient's physically aggressive behavior. Staff J stated that this was discussed by the Treatment Team following patient #14's 4/2/14 behavioral episode requiring physical restraint.
2. On 6/24/14 at approximately 1535 patient #14's physician (staff M) was asked if the Treatment Team encouraged staff to file criminal complaints against patient #14. Staff M stated that "this was not the Team's plan for (patient #14)." Staff M could not explain why patient #14's treatment plan had not been modified after the 4/2/14 episode of physical restraint.