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Based on interviews and review of the medical record, policies, procedures, observations and other pertinent documentation, the hospital failed to protect and promote the patients' rights as a result of staff's failure and unwillingness to come forward when patient abuse and patient harassment was observed due to fear of retaliation and reprisal from other staff as noted in in A0145. After an incident of witnessed abuse on 12/26/2009 the facility became aware of additional incidents of alleged abuse and harassment during its investigation. When the survey began, interviews with staff by the surveyors revealed an additional incident of alleged abuse and staff on Hitchman B who openly admitted that they were afraid to report incidents of alleged abuse by staff #2 . See the deficiency cited at A 0145.

Based on review of the medical record of patients, policies and procedures, staff and patient interviews, observations, and other pertinent information, it was revealed that hospital staff on Hitchman B unit were intimidated or afraid to report physical and verbal abuse and patient harassment due to fear of retaliation from other employees and fear that nursing administration would not seriously address their complaints as evidenced by:

Incident #1 - During an investigation of alleged abuse by staff , the surveyor learned of an incident of abuse that occurred on 12/25/2009. This incident of alleged abuse was observed by hospital staff on 12/25/09 at 9:00 am to patient #2 . Patient #2 is a 62 year old female admitted to Springfield Hospital Center on 11/4/04. The patient diagnoses included Schizophrenia disorganized, Dementia NOS, Hepatitis C, Diabetes, HTN, idiopathic Parkinson, constipation, seasonal allergies, increased liver function test and ammonia levels, dyspepsia and hyperprolactinemia.

Per interview of staff #1 by the surveyor on January 8, 2010, the staff stated that she was asked to assist in bathing patient #2 on 12/25/09 at around 9:00 am. Staff #1 stated she and staff #2 (a direct care worker and the alleged abuser) walked patient #2 into the Hitchman B tub room. Patient #2 undressed herself got in the tub and sat on a chair. As staff #2 was turning on the water to fill the tub, staff #3 came into the tub room and spoke to them. Staff #2 grabbed the shower head and turned on the water wetting patient #2's hair. Patient #2 screamed out that the water was too cold. Staff #1 stated that staff #2 then smacked patient #2 on the left side of her face near her hair line and temple areas. Staff #1, who was shocked by staff #2's action, stated that she looked at staff #3 who shook her head and then walked out the room. Neither staff who witnessed this incident intervened. Staff #1 stated that patient #2 immediately grabbed her face and started crying. Staff #2 finished bathing the patient and encouraged her to get dressed.

Staff #1 stated to the surveyor that she didn't report the abuse immediately because she was fearful of retaliation. She stated that "it's a known fact throughout Hitchman B if you report anything to the nursing supervisors in confidence about the unprofessional/abusive behavior of staff #2, she (staff#2) always finds out about what was said, and then the staff who told on her is subjected to mental and/or verbal harassment." Staff #1 stated that Staff #2 harassed other employees with text messages such as the one she received on break the day of this incident at 2:00 pm which stated "thanks, I can't believe you, I just want to know why."

Staff #1 did contact the ADON (Assistant Director of Nursing) early the following morning (12/26/09) to inform her of the witnessed abuse. The ADON contacted the RNM (Registered Nurse Manager) at approximately 1:50 pm on 12/26/09 to inform her of staff #1's report of witnessing the patient abuse that occurred on 12/26/2009. An investigation was initiated by the hospital. Staff #2 was informed of the allegation of abuse and was removed from the unit at 2:15 pm. She was placed on administrative leave and was later terminated .

A review of the police investigation for incident #1 revealed that in staff #3's police statement, staff #3 advised the hospital police that on 12/25/09 she walked into Hitchman B tub room just to say hello to her co-workers (staff #1 and staff #2). Staff #3 stated that "when she entered the tub room she witnessed staff #2 smack patient #2 in her face, which caused patient #2 immediately grab the left side of her face and start crying." Staff #3 also stated to the police officer that because of past incidents on the unit, she was afraid to report what she had seen to her supervisors on the unit because things reported to them have a way of getting back to staff #2. Staff #3 further stated she has been receiving text messages from staff #2 on her cell-phone asking her if she had her back in reference to what had occurred in the Hitchman B tub room.

Incident #2 - While the supervisor was addressing the 12/25/09 incident ( #1) on Hitchman B, the charge nurse reported another allegation of abuse that occurred earlier in the day at 8:00 am on 12/26/09 involving patient #3. Patient #3 is a 52 year old female admitted to Springfield Hospital Center on 4/22/03. The patient diagnoses include Schizoaffective Disorder, Bipolar, Opioid abuse in remission, Mild Mental Retardation, Hypercholesterolemia, Hypothyroidism, Abnormal pap smear, constipation and urinary incontinence. The patient had episodes of loud threatening behavior with accusations of mistreatment, poor hygiene and defiance toward staff interventions and assistance. She yells and screams for no apparent reason and often needs as needed (PRN) medications for her agitation.

According to staff #4's police statement of 12/26/09 and interview with surveyor on 1/11/10, staff #4 (a registered nurse) was trying to calm patient #3 who was yelling at staff to get her a new shirt because she didn't like the one she was wearing. Staff #4 tried appropriately to address the patient's yelling by telling her that once she stopped yelling she would get her a new shirt. Staff #4 stated that she overheard staff #2 telling patient #3 that "she couldn't change her shirt." At approximately 8:00 am staff #4 (the nurse) was sitting with the patient #3 trying to calm her. At that time staff #2 came over, interfered and demanded patient #3 go to the medication room for a PRN. Staff #2, who is a direct care aide, then grabbed the patient by her arm pulling her to her feet. Staff #2 then put her hands on patient #3's back and forcefully guided her to the medication window where staff #2 told the medication nurse to give the patient a PRN. Staff #4, the nurse, did advice the medication nurse that the patient did need her medication because she was unable to calm herself down. Staff #2 began walking away from the medication window then returned standing by patient #3 threatening her if "she didn't stop yelling she was going to take her purse too."

Staff #1, the medication nurse, also described witnessing staff #2 shoving and pushing patient #3 twice, once into the medication window ledge knocking the medication book off the ledge and a second time when staff #2 momentarily walked away, turned around walked back to the window and pushed patient #3 in her back. Staff #1 stated she overheard staff #2 being verbally abusive to patient #3 both in the day hall and at the medication window.

Incident #3 - On 1/8/10 at approximately 9:45am during the surveyor interview of staff #3, she corroborated staff #1's account of the witnessed abuse of patient #2. When asked by the surveyor if she witnessed any other abuse by staff #2 or other staff, she stated that the abrasion on patient #4's right abdomen (stomach) was due to the patient being kicked by staff #2. Patient #4 is a 59 year old female admitted to Springfield Hospital Center on 8/26/03. Patient #4 diagnoses include Schizoaffective Disorder - Bipolar type, Borderline Intellectual functioning by history, Hypothyroidism, Hyperlipidemia, Incontinence, Constipation, Arthritis and Obesity. The patient has an extensive history of legal and psychiatric problems. She continues to have loud outburst that require medication. She remains very delusional. She requires assistance with activities of daily living.

Staff #3 stated she wasn't sure of the date of the incident but recently patient #4 sat in the middle of the hallway floor while coming from the dining room and would not get up after staff verbally asked her. Staff #3 stated that she and staff #2 used a blanket to get the patient from the hallway to her bedroom. Once in the patient bedroom, staff #2 kicked the patient in her side. Staff #4 believed that the patient's right side was kicked. Staff #3 stated she was again shocked and fearful of staff #2 so did not report the abuse. The surveyor's interview with staff #3 was the first time the abuse of patient #4 was being reported as well as the hospital administration learning of the alleged abuse. The administration immediately initiated its procedures for investigating incident #4.

Patient #4 was seen by somatic physician. Patient #4 reported that staff kicked her on her side stating " it doesn't matter who she was, she is not here anymore." When asked when and where it happened, patient #4 stated "the day I fell, XXX (staff #2) came up and kicked me." When asked where did she kick you? Patient #4 stated "I'm fine it doesn't matter." When asked again when did this happen? Patient #4 stated "it happen on Christmas." The patient was seen by the psychiatrist and treatment team. The police and rights advisor were also notified as the staff was being interviewed. Fourteen days after the initial report of patient abuse, allegations of patient abuse by staff #2 were still being reported..

After the initial two reports of abuse on 12/25 and 12/26 and the administrative investigation was conducted, the hospital indicated to the surveyors that they began to conduct addtional investigation into the allegations of abuse on Hitchman B, which was in progress at the time of this survey. On 1/8/10 at 10:45 pm during police interviews of all staff on Hitchman B, more alleged incidents of patient abuse were reported. Staff #5 completed an incident report detailing that staff #2 put cold water on patient #4 during her tub bath ( Incident #4) and told patient #4 that she would not get her 8oz diet coke that day (patient #4 was on a behavior plan that if she walked to meals she would receive an 8oz diet coke) and staff #2 would see to it because she was there all day ( Incident #5). Staff #6 stated he saw staff #2, forcefully push patient #2 who was in a wheelchair across the day hall. Another staff #5 believed that incident had been reported to the Head Nurse. ( Incident #6)

The surveyors also conducted a review of the personnel action requests related to staff #2 and found documentation of two previous incidents of alleged abuse by staff #2 which occurred in July 2009. These incidents which were reported six days after they occurred, were investigated by the hospital police and administrative staff but could not be substantiated. The patients were not good historians and there were no other witnesses. As a result of the investigations of these two incidents administration believed that there were personal conflicts between the 2 staff alleged to have abused the patients and the staff who reported the allegations. All three staff were counseled.

The first of these incidents occurred on 7/15/09 when staff #7 reported that staff #2 purposely sat in a chair that patient #3 wanted. When another patient #5 tried to sit in the other chair staff #2 proceeded to put her feet in that chair to prevent patient #5 from sitting. When patient #5 crossed the day hall to sit in another chair, staff #9 started racing patient #5 to the chair making her run across the day hall to the chair. Staff #9 sat in the chair then staff #9 and staff #2 laughed at the patient who was upset and staff #7 assisted to calm down. Staff #2 was also overheard telling patient #8, "you call yourself a man, when you shit and piss all over yourself. "

Patient # 5 is a 51 year old female with diagnoses that include Schizoaffective Disorder, Depressive type, Rule out Dissociative Disorder, Obsessive Compulsive Disorder (OCD), Livedo Reticularis of legs with edema, History of vaginal cysts, Constipation, Moderate Tardive Dyskinesia, Seizure Disorder, Hypercholesterolemia, and Hypertension. The patient has episodes of jumping up and down, slapping thighs, talking in different voices, and mumbling to herself. The patient has rituals before sitting down (standing up, etc.).

The second case that occurred on 7/16/09 at approximately 2:00 pm, when staff #7 was putting supplies away for the day, she observed patient #3 in the tub room with staff #2 and staff #8. They were trying to make patient #3 have a bowel movement. When patient #3 could not go on command, the staff made her sit on the commode until she went. When the patient tried to get up staff #2 and #8 allegedly forced her back down by pushing or sitting on her. The allegation further stated that staff #2 teased patient #3 threatening to take away her personal belongings such as her shoes and purse, which made the patient agitated. Staff #2 then proceeded to put the patient's shoes on over her crocs while slinging the patient's purse over her shoulder stating that she was taking her things and if "she didn't have her bowel movement, she was going to start taking her shoes too." Staff #2 stated that she had done this in the past to her. Staff #2 said "hell I had all her fucking clothes on before." Staff #8 was standing over the patient with a toilet brush cleaners and threatened patient #3 stating that she was going to put the brush up inside her and referred to the brush as the pooper cleaner outer. Patient #3 became upset and was trying to get the brush from staff #8 and trying to hit her with her fists. Staff #8 turned her back on patient #3 as the patient hit her. Staff #8 and #2 were laughing at patient #3 who was upset to the point of crying, her face was red and she was trying to call for help on her imaginary phone speaking to her grandfather. Both staff were described as laughing the whole time.

These allegations of abuse for July 2009 were not reported by staff #7 for six days after they occurred. Staff also did not come forward with reports of incident #3 until the investigations of the 12/25 and 12/26 were conducted by the hospital's police and by this office. A review of the hospital policy on "Alleged Patient Abuse By Staff" section B states "Any staff member, who observes patient abuse; who has reason to believe that patient abuse has occurred; or receives a complaint of patient abuse shall immediately report the alleged abuse to their immediate supervisor." The review indicated that the hospital had policies and procedures regarding abuse but that staff in Hitchman B were not following them.

A review of the employees educational and orientation programs revealed that the employees are given the abuse policy to sign upon hiring at orientation. The staff signs an acknowledgement form that they received and read the information. The employees receive additional training on abuse through the PMAB (Prevention and Management of Aggressive Behavior) training and during the Annual Training Day (ATD). Despite staff signed acknowledgement that they have been made aware of the proper reporting of abuse or neglect and that the staff are required to review the entire policy and procedure for alleged patient abuse, this investigation revealed that staff on Hitchman B failed to comply with the hospital's reporting requirements in accordance with their orientation and training.

It should be noted that a review of other units within the hospitals were conducted which included interviews with staff and review of records from those units of the hospital. The surveyors found no evidence that the staff were afraid to report abuse or that incidents of alleged abuse were not reported. However, as a result of the attitudes and fears of staff on Hitchman B, patients on that unit were subjected to abuse and harassment from staff #2 .

Based on patient and staff interviews, review of the medical records, policies, procedures, observations and other pertinent documentation, the hospital staff failed to evaluate the nursing care provided to Patient #1 as evidenced by:

Patient #1 is a 58 year old female admitted to Springfield Hospital Center 6/29/04. Patient diagnoses include Schizoaffective Disorder Bipolar Type, Cognitive Disorder NOS, Multinodular Goiter, Partial Thyroidectomy, History of Pancreatitis from Valproic Acid and Edema of feet. The patient has a labile mood, delusional, responds to internal stimuli, inappropriate behavior, like taking others belongings and becomes agitated when staff intervenes. Patient #1 fell on 12/23/09 while using her walker, hitting her right knee and causing a four inch wide and one inch deep laceration requiring transfer to the nearest emergency department. The patient was treated and returned to Springfield Hospital Center.

The complaint received by the OHCQ indicated that patient flipped over her geri-chair. Two staff, when interviewed by the surveyor on 1/8/10, stated that after changing another patient they exited that patient's room and observed patient #1 sitting on the foot rest portion of the geri-chair with the chair in an upright position behind the patient. Both staff stated that patient #1 was not injured and kept saying "I want to walk." The patient was assisted back into the geri-chair by the two staff and the evening shift charge nurse.

A review of patient #1's medical record found no documented progress note, incident report nor was the incident documented on the Major Risk and Safety Event Log found on the patient's chart. There was no documented assessment of the patient after this un-witnessed fall.

A review of the hospital's policy for reporting of patient incidents and follow-up care revealed that the hospital staff failed to follow the policy when patient #1 who had three days prior fell injuring her right knee, was found on the floor by staff on 12/26/09. The patient was not assessed as required and per interviews with the staff frequently slid out of her chair or rocked from side-to side until she tipped the chair over.

Per the Individual Plan of Care under intervention for the problem Degenerative Joint Disease it is written to monitor the patient#1 for falls. The Major Risk and Safety Event Log starting in July of 2009 lists the date and times of patient #1's falls as follows:

7/23/09 at 955am patient #1 attempted to get up from a geri-chair, it flipped and she fell.
8/4/09 at 10:40am patient sitting a straight back chair fell asleep and slid to floor.
8/30/09 at 2:45pm got up from loveseat and fell
9/9/09 at 10:10am fell forward from chair while sleeping.
10/10/09 at 11:05am patient fell in day hall
12/23/09 at 2:25pm fell on right knee


There was no documentation regarding patient#1 being found on the floor on 12/26/09.

Despite the documented fall risk, the hospital failed to evaluate the patient who was identified as a fall risk but was not re-evaluated when the Major Risk Event Log showed the patient was falling on average of once per month. Additionally, the hospital staff failed to follow the policy for reporting and documentation of falls and the hospital staff failed to change or re-evaluate the plan of care after the patient falls.