HospitalInspections.org

Based on interview, record review and policy review, the facility failed to provide a safe environment when they failed to recognize staff to patient abuse and failed to remove two of two alleged perpetrators (Staff E and Staff T) from patient care. The facility also failed to ensure staff followed their policy for reporting alleged patient abuse. These failures resulted in an unsafe environment for all patients and had the potential to place all patients within the facility at risk for abuse. The facility census was 91.

Findings included:

1. Record review of the facility policy revised 01/12/16 "Investigation of Institutional Abuse/Neglect Allegations" showed:
-All patients have the right to be provided with protective oversight while a patient in the hospital.
-It is required that all hospitals provide an effective process for the reporting of patient abuse, by staff, patient, or others.
-If an allegation of abuse or neglect is made by a patient, the staff member to whom the allegation is made will report the allegation to the House Nursing Supervisor who will assist that staff member in notifying the appropriate state reporting authority.
-The Nursing Supervisor, Department Manager will notify Director of Nursing.
-If the alleged perpetrator is a staff member, that staff member will be suspended and not allowed to work at the hospital until the hospital's investigation is completed.
-The Director of Risk Management will investigate the incident with the persons involved documenting facts surrounding the suspected abuse or neglect.

2. Record review of Patient #9's medical record showed he was admitted on 02/08/17 with a diagnosis of Bipolar Disorder (a mental disorder marked by alternating periods of elation and depression). Documentation on 02/11/17 by Staff T, Registered Nurse (RN), showed the "night shift tech entered the patient room to take vital signs (VS, temperature, pulse, respiration and blood pressure). The patient became agitated and threatened the tech, saying "I am going to kick your ass for waking me up" and the patient jumped out of bed and raised his fist." Staff T further documented that as he entered the room the patient jumped back into bed.

During an interview on 02/22/17 at 3:30 PM, Staff D, Mental Health Tech (MHT), stated that:
-He walked into Patient #9 room (a four bed room with two other patients in beds) to take vital signs.
-Patient #9 was loudly mumbling and cursing while he took another patient's VS.
-He placed the blood pressure cuff on Patient #9's arm
-Patient #9 took the blood pressure cuff off and flung it at him.
-Patient #9 was cussing and ran toward him with a raised fist.
-He deflected the fist and moved around Patient #9.
-Patient #9 fell to the floor.
-Patient #9 jumped up and got back into bed and covered up still yelling and cussing.
-Staff D yelled out the door for help.
-Staff T, RN Charge Nurse, and Staff E, Licensed Practical Nurse (LPN), came to the door and asked if help was needed.
-Patient #9 came to him (Staff D) approximately 15 minutes later and apologized for his behavior.
-He did not see any injury to the patient's face.
-He did not assess the patient after the fall.
-He did not report the fall to the Charge Nurse.
-He did not complete an incident report of the patient's fall.
-He expected Staff T to complete the incident report and inform the House Supervisor.

During an interview on 02/23/17 at 7:30 PM, Staff T, RN, Charge Nurse, stated that:
-He and the LPN were standing at the nursing station preparing to make rounds.
-He heard a call for help from Patient #9's room and he and the LPN went to the room.
-The patient was standing and jumped into his bed while verbally threatening the MHT (Staff D).
-He remained in the room while VS were taken on another patient.
-He and the MHT left the room and he asked Staff D what had happened.
-Staff D stated that the patient had drawn back his fist.
-He did not know the patient had fallen.
-A few minutes later, the patient approached him and the MHT and said he was sorry.
-He did not observe any redness or swelling to the patient's eye.
-He was assigned another unit on Monday, his next day to work.
-At no time was he suspended.

During an interview on 02/22/17 at 4:33 PM, Staff E, LPN, stated that:
-While standing at the nursing station, he heard yelling coming from a room and he and Staff T went to the door way and saw the patient pulling the covers up over himself in bed.
-Staff D told them that the patient threw a punch at him and he pushed him onto the bed.
-The patient did not complain of any injury when he saw him at the nurse's station later.

During an interview on 02/23/17 at 10:42 AM, Staff I, Charge Nurse Acute Unit, stated that:
- At report that morning, a mention was made of the patient being aggressive when awakened.
- She went to see the patient and get his perspective of the events.
- The patient stated he was startled and went to the opposite side of the bed of the MHT.
- The Tech "jumped" him.
- He fell on the floor with his head next to the bed.
- He stated that the "two nurses sat on me".
- She reported this to Staff K, House Supervisor for day shift on week-ends, and gave her the State phone number.
- The patient's eye was puffy and a little discolored and the next day (Sunday) he had a black eye.
- She did not document what the patient told her or document her assessment of his eye.

Staff I failed to recognize the potential for abuse and did not follow the facility policy of assessment for injuries to the patient.

During an interview on 02/23/17 at 9:00 AM, Staff J, House Supervisor, stated that:
-She was not called by Staff T regarding the patient fall.
-She was informed on Tuesday night (three days after the incident).
-The process for suspected abuse/neglect should be to inform the House Supervisor, notify the Administrator on call and send the staff home.

During an interview on 02/23/17 at 9:15 AM, Staff K, House Supervisor, stated that:
-The patient approached her at approximately 3:00 PM on 02/11/17 and asked that a photograph of his eye be taken because he had been "tackled" that morning when VS were being taken.
-She observed "a little redness" on the patient's eye.
-The day charge nurse had said that the patient had told her of the incident also.
-The patient's name was entered on the board for the Nurse Practitioner to see on Sunday when she was rounding.

Staff K failed to recognize the potential for abuse and did not follow the facility policy for reporting.

3. Record review of the facility Internal Investigation of the incident with Patient #9, showed Staff U, Director of Quality, interviewed Patient #9 on 02/13/17. The patient reported that Staff D, MHT, tackled him and he fell to the floor hitting his face and two other nursing staff (E and T) "started to sit on his bed on his legs."

During an interview on 02/22/17 at 5:05 PM, Staff U, Director of Quality, stated that he did not consider the allegation that staff sat on the patient's legs as an allegation of abuse but of improper therapeutic intervention. The staff involved were assigned to another unit.

Record review of the facility staff schedule showed Staff E continued to work with patients
on 02/11/17, 02/12/17, 02/13/17, 02/17/17, 02/18/17 and 02/19/17. Staff T continued to work with patients on 02/13/17, 02/14/17, 02/15/17, 02/16/17, 02/17/17, 02/20/17, 02/21/17 and 02/22/17.

During an interview on 02/22/17 at 5:30 PM, Staff F, Director of Nursing, stated that the failures of the facility were:
- Not assessing the patient after the fall;
- Not reporting the fall within the policy guidelines;
- Not informing the physician,
- Not suspending the staff involved until the investigation was completed,
- Not documenting the investigation of Staff T and Staff E.

The facility failed to follow their abuse policy when staff did not report as directed in a timely manner and did not suspend Staff E and Staff T until an investigation of alleged staff to patient abuse was completed.