HospitalInspections.org

Based on record review and staff interview, it has been determined the hospital failed to protect a patient's right to be free from all forms of abuse or harassment.

Findings are as follows:

1. The hospital failed to ensure patients receive care in a safe setting relative to a patient who was issued corded earbuds, an item considered "restricted" by the hospital, to strangulate themselves (Refer to A-0144).

2. The hospital failed to update a patient's treatment plan relative to their safety status (Refer to A-0144).

3. The hospital failed to document the use of restricted items used by a patient on two separate occasions where the patient tied corded earbuds to their neck (Refer to A-0144).

4. The hospital failed to protect a patient who was physically assaulted by a hospital employee who had previous allegations. (Refer to A-0145).

5. The hospital failed to report an allegation of abuse per hospital policy, Federal and State law, (Refer to A-0145).

6. The hospital failed to ensure employees are trained annually on abuse, neglect, and mistreatment per hospital policy, (Refer to A-0145).

Based on record review and staff interview, it has been determined that the hospital failed to ensure patients receive care in a setting that a reasonable person would consider safe relative to a patient (Patient ID #1) who was issued corded earbuds, an item considered "restricted" by the hospital. The patient then attempted to strangulate him/her self. Additionally, the hospital failed to update the patient's treatment plan relative to their safety status and failed to document the use of restricted items used by this patient on two separate occasions where the patient tied corded earbuds to their neck.

Findings are as follows:

On 5/22/2023, the Rhode Island Department of Health received a report which stated that on 5/21/2023, Patient ID #1 approached an employee while gesturing to their neck which was covered by a hospital gown. The report states that the patient had tied an earbud cord as well as plastic bra straps to their neck and was responsive, but lethargic and disoriented.

The following hospital policies and documents were reviewed as part of this investigation:

1. "Nursing Safety: Environmental Safety Check" effective 5/22/2023

2. "Admission to the Unit, Initial Nursing Assessment, Initial Care plan and Nursing Progress Note" effective 4/21/2021

3. "Restricted Use Item Log"

The hospital's policy titled, "Nursing Safety: Environmental Safety Check" effective 5/22/2023 states in part,

"Policy:

The purpose of this policy is to mitigate risk through an active review of environmental concerns. This includes proper storage and monitoring of prohibited and restricted items ...

Procedure for Environmental Check ...

...3. The staff person will bring a copy of the restricted items log with them and update all entries on the original log as needed.

4. Content of checks

...d. In addition, the back side of the Environmental Safety Check Sheet contains additional items to be monitored on three specialty units: Addictions, Adolescents and Geriatrics ...

Patient Belongings: Prohibited and Restricted Item List ...

...Restricted Use Items:

Restricted items may be used by patients on appropriate levels or with a doctor's order ...

...CD player/headphones ..."

Review of blank document titled, "Restricted Use Item Log" states in part,

"Prior to 3rd shift all items that cannot remain with patient overnight must have time in with staff initials. All items that have been assessed as appropriate to remain with patient overnight must be carried over to the new sheet by 3rd shift."

The hospital's policy titled, "Admission to the Unit, Initial Nursing Assessment, Initial Care plan and Nursing Progress Note" effective 4/21/2021, states in part:

" ...8. Reassessment should be done at any significant change in the patient's condition. Such as medical status, a fall, restraint or seclusion or change in safety status.

...b. Changes in status must be addressed in the treatment plan by the RN [Registered Nurse], including RN signature and date the treatment plan is updated."

Record review for Patient ID #1 revealed that she/he was transferred to this hospital in April of 2023 from an acute care hospital after undergoing two shunt revisions. Patient ID #1's medical history includes hydrocephalus (an accumulation of cerebrospinal fluid in the brain) secondary to a pseudotumor cerebri (pressure increase inside the skull) with a shunt (a device surgically placed to drain cerebrospinal fluid), migraines, traumatic brain injury, seizures, schizoaffective disorder, and anxiety.

Review of a "Shift Note" dated 5/6/2023 revealed Patient ID #1 approached a nurse on the unit with a pair of headphones "tied loosely around [his/her] neck". The note further states that Patient ID #1 was directed to stay on the unit for their safety.

Patient ID #1's record failed to reveal evidence that the treatment plan was updated on 5/6/2023 to reflect goals and interventions relative to this patient's self-injurious behavior with use of the corded headphones/earbuds.

Record review of a progress note dated 5/21/2023 for Patient ID #1 completed by the physician on call indicates that the physician responded to a "code blue" on this date to evaluate this patient after the patient attempted to strangulate him/herself with a headphone cord and was noted by staff to be cyanotic (a bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood).

Further review of this note revealed that Patient ID #1 was sent out to an acute care hospital for an evaluation due to cyanosis and continuous complaints of shortness of breath, neck pain, and chest pain. This patient was medically cleared and returned to the psychiatric hospital.

Patient ID #1's record failed to reveal evidence that the treatment plan was updated on 5/21/2023 to reflect goals and interventions relative to this patient's self-injurious behavior with the use of corded headphones/earbuds.

During a surveyor interview on 5/23/2023 at 3:15 PM and at 3:37 PM with the Director of Risk Management, she revealed that on 5/21/2023, Patient ID #1 approached a Mental Health Worker, pointed to his/her neck and fell to the ground. The Director states that Patient ID #1 had "wired earbuds" tied tightly around the neck as a well as a "bra strap" which were covered by a hospital gown. She revealed that the wired earbuds used by Patient ID #1 to tie around his/her neck on 5/6/2023 and on 5/21/2023, were issued by the hospital. When asked if Patient ID #1 had a physician's order for the wired earbuds, the Director of Risk Management stated Patient ID #1 did not have an order use them.

Record review of Patient ID #1's treatment plan with the Director of Risk Management at 4:00 PM on 5/23/2023, revealed that the plan was initiated on 4/6/2023, however, the Director was unable to find evidence that detailed goals and interventions specific to this patient's change in safety status and their attempts to strangulate him/herself with corded earbuds/headphones.

During an additional interview on 5/24/2023 at 11:58 AM with the Director of Risk Management, she indicated that patients are provided with earbuds when they are provided with a radio/MP3 player as this is the only way they can hear it. She stated that it is understood by staff that when a patient receives a radio/MP3 player, earbuds are issued as well.

Record review of the unit's "Restricted Use Item Log" for 5/6/2023 and 5/21/2023, failed to reveal evidence that a radio/MP3 player with wired earbuds or headphones were signed out by staff for Patient ID #1 to use on these dates.

During a surveyor interview on 5/24/2023 at 11:58 AM with the Director of Risk Management, she indicated that radios should be signed out by staff per hospital policy since they are included in the list of restricted items for the unit. She indicated that staff may have known Patient ID #1 had the earbuds since one of the patient's coping strategies involve listening to music. However, the Director of Risk Management was made aware that staff did not sign out a radio or earbuds to Patient ID #1 according to the "Restricted Item Log" on 5/6/2023 when the patient tied the earbuds loosely to their neck nor on 5/21/2023 when the patient tied the earbuds tightly, along with a "bra strap," to their neck.

Based on record review and staff interview, it has been determined that the hospital failed to ensure patients are free from all forms of abuse for a patient (Patient ID #1), who was physically assaulted by a hospital employee. Additionally, the hospital failed to report an allegation of abuse relative to Patient ID #2 and failed to follow hospital policies relative to annual abuse, neglect, and mistreatment education for 2 of 9 employees reviewed.

Findings are as follows:

1. According to a report submitted to the Rhode Island Department of Health on 5/4/2023, on 5/3/2023 at 12:20 PM in the Delmonico 2 Unit, Employee A was observed by another Employee to grab Patient ID #1 by the neck, let go, and then forcefully shove Patient ID #1 with both hands. This resulted in Patient ID #1 to fall to the floor, hit the back of their head and immediately complain of head, neck, and left arm pain. The report further states that according to Employee A, Patient ID #1 had grabbed his genitals.

Further review of this report revealed that Patient ID #1 was sent out to another hospital to be evaluated. While awaiting to leave the unit, Patient ID #1 "was tearful and continued to endorse head, neck, and wrist pain."

The hospital 's policy titled, "Reporting Patient to Patient and Staff to Patient Abuse" effective April 13, 2021, states in part:

" ...IV. Definitions ...

...1) Staff-to-Patient Abuse includes, but is not limited to:

A) Abuse- assault against a patient or intentionally engaging in a pattern of harassing conduct which causes, or is likely to cause, physical or psychological harm to patient (e.g., ridiculing or demeaning of patient, threatening, or cursing at a patient) ..."

Surveyor review of Patient ID #1's medical record revealed that she/he was transferred to this hospital in April of 2023 for inpatient treatment from an acute care hospital after undergoing two shunt revisions. Patient ID #1's medical history includes hydrocephalus (an accumulation of cerebrospinal fluid in the brain) secondary to a pseudotumor cerebri (pressure increase inside the skull) with a shunt (a device surgically placed to drain cerebrospinal fluid), migraines, traumatic brain injury, seizures, schizoaffective disorder, and anxiety.

Record review of a "Shift Note" for Patient ID #1 dated 5/3/2023 entered by Employee B, Registered Nurse (RN), states in part that Patient ID #1 had expressed concerns regarding the new shunt revision to his/her brain therefore
she/he was sent out to an acute care hospital for "further evaluation."

During a surveyor interview on 5/10/2023 at 10:53 AM with Employee B, RN, she revealed that on 5/3/2023 she was Patient ID #1's primary nurse and she called for assistance as Patient ID #1 was verbally threatening and aggressing at staff. Employee B stated she was at Patient ID #1's doorway when she told Employee A that a chair restraint would be required, and she proceeded to assign limbs, but Employee A volunteered to take an arm. Employee B stated that she saw Employee A approach Patient ID #1, and both engaged in a hand scuffle which consisted of "lots of grabbing". Employee B stated that she then saw Employee A "fully extend his arm with his hand around [Patient ID #1's] neck." Employee B further explained that Employee A had his hand completely wrapped around Patient ID #1's neck. Employee B stated that she then saw Patient ID #1 stop and Employee A "retracted his hand and placed both of his hands on [Patient ID #1]" and "forcefully push [Patient ID #1] back." Patient ID #1 fell back approximately a foot and landed on his/her back and was upset and crying while on the floor. When asked if she saw Patient ID #1 grab Employee A's genitalia, she stated she did not.

During a surveyor interview on 5/10/2023 at 12:08 PM with Employee C, RN, she indicated on 5/3 she was working on Delmonico 2 when assistance was called for a restraint to be applied to Patient ID #1. Employee C indicated that she was outside of the room but from her point of view, she saw Employee A with both of his hands up and suddenly Patient ID #1 ended flat on the floor. Employee C stated that Employee A came out of the room breathing heavily and she directly asked him. Employee C asked Employee A if he had pushed Patient ID #1, he stated Patient ID #1 had grabbed his genitalia.

During a surveyor interview on 5/10/2023 at approximately 1:50 PM with Employee D, Mental Health Worker (MHW), he stated that he was present on 5/3/2023 and was part of the restraint that was to be applied to Patient ID #1. Employee D stated that he was behind Employee A and was assigned to hold Patient ID #1's ankle for the restraint. Employee D stated that he recalls Patient ID #1 lunging towards Employee A, he saw Employee A's hands go up and then Patient ID #1 was laying on the ground. When asked if he saw Patient ID #1 grab Employee A's genitalia, he stated he did not.

During a surveyor interview on 5/10/2023 at approximately 2:25 PM Employee E, MHW, stated that when a call for support was made to assist in a restraint on Delmonico 2, she was the person who grabbed the restraint chair. Employee E stated she saw Employee A coming out of the room breathing heavily and saw Patient ID #1 on the floor crying.

During a surveyor interview on 5/11/2023 at 9:30 AM with Employee F, MHW, he indicated that after a call for support was made on Delmonico 2, he responded and revealed that Patient ID #1 was loud and boisterous. Employee F indicated that Patient ID #1 was unable to be redirected and had to be restrained. Employee F stated that upon approaching Patient #1's room, he witnessed a "scuffling exchange" between Employee A and Patient ID #1 but did not see Patient ID #1 grab Employee A's genitalia with his/her hands. Employee F stated that he then saw Employee A standing within a foot of Patient ID #1 and "Forcefully push" Patient ID #1 with two hands causing Patient ID #1 to fall to the ground.

During a surveyor interview on 5/11/2023 at 11:03 AM with Employee A, Certified Nursing Assistant (CNA), the alleged aggressor, he indicated that he responded to a call for support on Delmonico 2 for Patient ID #1 who was acting "erratic, out of control and was threatening towards staff." Employee A stated that Patient ID #1 was told several times that she/he would be restrained. Employee A revealed that after going "back and forth" with Patient ID #1, a nurse entered the room and he followed. Employee A stated that he was confused about what the plan was as the nurse continued to attempt redirection with Patient ID #1 so he "stood there" awaiting instructions. Employee A stated that he was standing within an arm's length of Patient ID #1 when Patient ID #1 reached and grabbed his testicles. Employee A then revealed he "shoved [him/her] away from me" as his back was "against the wall" and he "had nowhere to go." Employee A revealed that after shoving Patient ID #1, Patient ID #1 fell backwards to the ground onto her back.

During a surveyor interview on 5/11/2023 at 12:07 PM with Employee G, RN, he stated that he was working on another unit when he heard the call for support in Delmonico 2 and responded. Employee G stated that staff formed their standard formation to apply a restraint on Patient ID #1 and Employee A was in front of him. Employee G revealed that as everyone was approaching Patient ID #1's room, Employee A "jumped ahead" and it looked like Patient ID #1 lunged towards Employee A's crotch area but he did not witness Patient ID #1 grabbing Employee A's genitalia. Employee G stated that from his point of view, it looked like Employee A extended his left arm, placed it on Patient ID #1's chest and neck area, and then saw Employee A push Patient ID #1 with both of his hands causing Patient ID #1 to fall backwards and hit the floor. Employee G revealed that Patient ID #1 was tearful while stating, "Why would he do that? I know what I did was wrong but why would he do that?"

During a surveyor interview on 5/11/2023 at approximately 1:00 PM with the Director of Risk Management, she was made aware that Employee A acknowledged that he pushed Patient ID #1 which resulted in him/her to fall to the floor on his/her back causing him/her to become tearful and feel pain in his/her head, neck, and wrist.

2. The hospital 's policy titled, "Reporting Patient to Patient and Staff to Patient Abuse" effective April 13, 2021, states in part:

" ...IV. Definitions ...

...1) Staff-to-Patient Abuse includes, but is not limited to:

B) Abuse- assault against a patient or intentionally engaging in a pattern of harassing conduct which causes, or is likely to cause, physical or psychological harm to patient (e.g., ridiculing or demeaning of patient, threatening, or cursing at a patient) ...

...V. Procedure.

1) Any staff member or employee of the hospital, or any person within their professional capacity, who has knowledge of, or reasonable cause to suspect patient abuse, neglect or mistreatment shall immediately report his or her concerns.

...C) The staff member should complete an Occurrence report ..."

...2) The person receiving the report will assist the staff member in completing an occurrence report and will notify the Director of Risk Management Immediately ..."

Record review revealed that Patient ID #2, who has a diagnosis of autism spectrum disorder, was admitted to the hospital in April of 2023 on emergency certification due to increased agitation and self-injurious behavior.

Further review of Patient ID #2's record revealed she/he had a physician's order to be observed constantly by two employees due to aggressive behaviors towards himself/herself and others.

During a surveyor interview on 5/10/2023 at 10:53 AM with Employee B, RN, she revealed that Employee A had been involved in another allegation of abuse towards Patient ID #2, an Autistic patient, where Employee H, Certified Occupational Therapy Assistant, had been a witness. Additionally, Employee B revealed that according to Employee H, Employee H reported the incident to the Director of Occupational Therapy.

During a surveyor interview on 5/11/2023 at 8:15 AM with the Director of Risk Management, she revealed that on 4/26/2023, Employee A and Employee H were assigned to Patient ID #2 and according to Employee H, Employee A forcefully pushed Patient ID #2 back to bed. The Director of Risk Management stated that Employee A denied this during the investigation and the incident was found to be unsubstantiated.

During a surveyor interview on 5/11/2023 at 12:36 PM with Employee H, she revealed that on 4/26/2023 during the 7:00 AM to 3:00 PM shift, she and Employee A were in Patient ID #2's room and Patient ID #2 would continuously stand up and say, "on the unit, on the unit," which was the patient's way of saying he wanted to go out onto the unit, but Employee A was making Patient ID #2 stay in the room. Employee H stated that she observed Employee A cross his arms across his chest and forcefully push Patient ID #2 telling him/her she/he was not going on the unit. Employee H revealed that Employee A got close to Patient ID #2's face and said, "you need to be a good boy, or I'm going to call mommy and tell her you're being a bad boy." Employee H also stated she observed Employee A grab Patient ID #2's shoulders and push him/her. When asked if she had reported her concerns regarding Employee A, she stated she had not reported anything that day after completing her shift but revealed she reported her concerns the following day to the Director of Occupational Therapy.

During a surveyor interview on 5/11/2023 at 11:03 AM with Employee A, CNA, he denied pushing Patient ID #2 at any time but stated he used a stern voice to set expectations with Patient ID #2.

During a surveyor interview on 5/11/2023 at 1:50 PM with Employee J, CNA, he indicated that he recalls working on 4/26/2023 with Employee A and Employee H. Employee J stated that he recalls the stern and direct verbalization of "you need to be a good boy, or I'm going to call mommy and tell her you're being a bad boy" from Employee A towards Patient ID #2.

During a surveyor interview on 5/11/2023 at 1:18 PM with the Director of Occupational Therapy, she indicated that Employee H reported her concerns regarding Employee A and acknowledged she entered the report in the hospital's reporting system incorrectly.

During a surveyor interview on 5/11/2023 with the Director of Risk Management she indicated that the Director of Occupational Therapy came to her on 5/10/2023 to report that she had entered an incident report regarding an allegation of abuse from Employee A towards Patient ID #2 which was witnessed by Employee H. The Director of Risk Management revealed that she did not receive this report against Employee A, nor did she report this allegation to the Rhode Island Department of Health, since the Director of Occupational Therapy did not enter the report correctly in the hospital's incident reporting system. Additionally, she indicated that Employee H should have entered an occurrence report.

3. The hospital's policy titled, "Reporting Patient to Patient and Staff to Patient Abuse" effective April 13, 2021, states in part:

...Education

1) The Hospital will provide regular staff education on hire and annually related to patient abuse, neglect, and mistreatment ..."

Record review revealed that 2 of 9 employees, Employee K (physician) and Employee L (physician), did not complete their annual abuse, neglect, and mistreatment education per hospital policy.

During a surveyor interview on 5/11/2023 at 2:19 PM with the Director of Risk Management, she was unable to provide evidence that Employee K and Employee L completed their annual abuse, neglect, and mistreatment training per hospital policy within the past year.