HospitalInspections.org

Based on observation, staff interview, and review of facility documents, it was determined that the Governing Body failed to demonstrate that it is effective in carrying out the operation and management of the facility. The Governing Body failed to provide necessary oversight and leadership as evidenced by the lack of compliance with the following Condition of Participation:

482.13 Patient Rights (Cross refer Tag 0115)

Based on observation, facility document review, staff interviews, medical record review, and review of facility policies and procedures, it was determined that the facility failed to protect and promote each patient's rights.

Findings include:

1. The facility failed to to ensure that all patients receive care in a safe setting. (Cross refer Tag 0144)

2. The facility failed to ensure that all patients are afforded the right to be free from all forms of abuse or harassment. (Cross refer Tag 0145)

Based on observation, staff interview, medical record review, facility document review, and review of facility policies and procedures, it was determined that the facility failed to ensure that all patients receive care in a safe setting.

Findings include:

Reference: Facility policy and procedure Subject: Hospital Patient Rights states, "... A patient in --[facility name]-- has the following rights: ... [36th bullet, page 7] To receive care in a safe setting by staff educated in patient rights; ..."

Review of facility video tape recordings, staff interviews, facility document review, and medical record review indicated that Patient #1 was repeatedly threatened and poked with a needle by Staff #11 while under his/her care on 5/12/16 and 5/15/16. Staff #11 did not provide a safe environment for Patient #1. Please refer to 482.13(c)(3) at Tag 0145 for details and description.

Based on observation, staff interviews, medical record review, facility document review, and review of facility policies and procedures, it was determined that the facility failed to ensure that all patients are afforded the right to be free from all forms of abuse or harassment.

Findings include:

Reference #1: Facility policy and procedure Subject: Hospital Patient Rights states, "... A patient in --[facility name]-- has the following rights: ... [19th bullet] To be free from neglect; exploitation; and verbal, mental, physical or sexual harassment or abuse. ..."

Reference #2: Facility policy and procedure Subject: Closed Circuit Television Monitoring and Recording at --[facility name]-- states, "POLICY: --[facility name]-- may utilize Closed Circuit Television (CCTV) monitoring and recording equipment at specific --[facility name]-- locations and services to monitor public and specific non-public/clinical high risk areas as mandated by regulatory oversight agencies, including the inpatient Behavioral Health and Psychiatric Intervention Program units. ... PROCEDURE: Behavioral Health Video Surveillance: 1. Video surveillance cameras shall be installed to monitor only those areas identified as requiring surveillance for safety and security purposes. ..."

Reference#3: Facility policy and procedure Subject: Child Abuse and Neglect states, 'POLICY: To comply with the New Jersey State reporting laws, protective custody laws and to cooperate with the Division of Child Protection and Permanency (DCP&P) in providing proper care of abused or neglected children. The social worker, or in his/her absence, the registered nurse, physician or administrative supervisor on duty is the designated liaison for child abuse reporting. ... PROVISIONS FOR REPORTING: The state of New Jersey mandates that any person having reasonable cause to believe that a child has been subject to child abuse, or any act of child abuse, shall report the same promptly to the New Jersey Division of Child Protection and Permanency by telephone or otherwise pursuant to N.J.S.A. 9:6-8.10. ...NOTIFICATION OF DIVISION OF CHILD PROTECTION AND PERMANENCY: The Social worker (sic) will be notified to call Division of Child Protection and Permanency. Parental consent is not required for this reporting. If unavailable, the physician, nurse or Nursing Supervisor will notify the Division of Child Protection and Permanency. ... DOCUMENTATION: Documentation in the medical record should be completely objective and descriptive ..."

1. On 5/24/16 at 10:40 AM, the Psychiatric Intervention Program (PIP) Unit within the ED was toured in the presence of Staff #6.

a. Staff #7 stated in interview there is a Behavioral Therapist (BT) assigned to the cameras at all times; the patient rooms and unit are on video surveillance observation. The cameras do record thru the Security Department. We notify patients on admission that they are on video surveillance, and we ask them to change on admission in one of the two patient bathrooms on the unit.

b. Signs are posted on the unit to communicate to patients/ staff that the unit has video cameras.

c. A BT, Staff #8, was interviewed. During a discussion of Patient Rights, Staff #8 stated that Patient Rights are posted in each patient room, and there is annual education staff have to complete on the computer and sign off on. Staff #8 stated this training includes abuse and neglect. Staff #8 stated he/she would report any unsafe condition to the Charge RN/ Team Leader, and then to the Nurse Manager.

2. On 5/24/16, review of Medical Record #1 evidenced the following:

a. A physician addendum progress note dated and timed 5/16/16 at 12:55 PM stated, "I was asked to see patient, by Dr. --- for independent medical exam for possibility of staff abuse of patient. There was report of possible inappropriate restrain(sic)a patient by staff with injury to child's right wrist. Child is mentally impaired and is unable to provide any history. ..."

b. A physician re-examination progress note dated and timed 5/17/16 at 9:38 AM stated, "Was asked to see patient to evaluate for potential left hand or foot injury and aso (sic) for any sign of puncture wounds. Left hand and foot both without swelling, without bruising or appearance of tenderness. The rigth (sic) volar arm has one newer appearing bruise that is large but I am told had blood draw there a couple of days ago. The other small bruises I can not (sic) say when they occurred but given there appearance could infer that they may have occurred from care givers trying to restrain, I am to understand that the child kicks and bites at times, but I do not see any puncture mark in the cente (sic) of any of these. . (sic) I do not see any evidence of needle/puncture marks otherwise at this time. . (sic)"

c. A physician addendum progress note dated and timed 5/18/16 at 12:58 PM stated, "Addendum: On 5/16/16 at 5 PM, I along with --[Staff #2, Clinical Director]--, --[Staff#16, Case Manager of PIP]--, and --[Staff #10, Director of Security]-- had a meeting with the patient's guardian/sister ---. We disclosed to her that we had received an allegation of abuse by a staff member against her brother. We also disclosed that our investigation led to us needing to notify the police. We answered her questions and concerns."

3. On 5/24/16, review of facility documentation indicated an anonymous report was made on 5/15/16 stating, a staff member working in the PIP Unit witnessed an RN threaten to stick, and did repeatedly stick an autistic ten year old patient with a needle at least six (6) times for not behaving, and the child cried. It was alleged the RN stuck the patient in his/her left upper arm, knees, left thigh, right hand, and fingers. The RN is alleged to have also bent the child's fingers back causing an audible crack.

4. On 5/24/16 at 11:10 AM-12:00 PM, the Security footage of the PIP Unit for the dates of 5/12/16 and 5/15/16 was viewed in the presence of Staff #2, Staff #6, and Staff #9. The video is visual only [no sound recording]. The video's still shots and running footage showed Staff #11 brandishing and poking Patient #1 with a needle in several instances.

a. Staff #2 confirmed that there was no IM medication ordered for Patient #1 at that time, and that Staff #11 is just threatening Patient #1 with the needle.

5. During review of the video footage, it was observed that Patient #1 had a staff member/ sitter in his/her room during the times Staff #11 was threatening and poking Patient #1 with a needle, on the night-shift of 5/12/16 and the day-shift of 5/15/16.

a. On 5/24/16 at 12:22 PM, Staff #2 stated that we placed this child on 1:1 watch/ observation as a nursing measure.

6. Staff #13 was assigned to the 1:1 observation of Patient #1 on the night-shift of 5/12/16. Staff #12 was assigned to the 1:1 observation of Patient #1 on the day-shift of 5/15/16. Each of these Patient Care Associates (PCAs) was observed in Patient #1's room during the times/ instances in which Staff #11 threatened and/or poked/jabbed Patient #1 with a needle.

a. Review of the job description for a Patient Care Associate states under POSITION SUMMARY, "... The Associate regularly communicates observations and data collection to the Clinical Associate. ...", under PERFORMANCE EXPECTATIONS, that the PCA "Demonstrates the ability to perform the department specific competencies as listed on the Assessment and Evaluation Tool.", and under REPORTING RELATIONSHIP, "This position reports to Nursing Unit leadership."

(i) Review of Staff #12 and Staff #13's Assessment and Evaluation Tools indicates each employee was signed off for competencies in Patient Rights.

b. Review of Staff #12's and Staff #13's education files indicated each employee completed the facility's annual education which encompassed child abuse.

7. There was no evidence Staff #12 or Staff #13 reported the instances of needle poking and threats to Patient #1 by Staff #11 to the Charge RN on duty, or to any nursing leadership, during their shifts, as per the PCA job description.

8. The PIP unit staffing sheets for the night-shift of 5/12/16 and day-shift of 5/15/16 was reviewed. There was no indication on the staffing sheets of the BT that was assigned to observe the video recordings of the unit monitors on either shift (Refer to Staff #7's interview #1 above).

a. Per Staff #2 on 5/24/16 at 2:12 PM, we assign someone to watch the cameras. The BTs usually rotate or share the video assignment throughout the shift. Per Staff #2, Staff #14, a Mental Health Therapist/ Screener was watching the video monitoring/cameras on the day shift on 5/15/16.

9. The facility has a staff member watch the unit cameras for safety as per Reference #2 above. The person(s) watching the video surveillance failed to identify that Patient #1's safety was in jeopardy while Staff #11 repeatedly brandished a needle in front of him/her, and repeatedly stuck him/her with the needle.

10. Staff #2 and Staff #6 reported in interview that the facility notified the NJ Division of Mental Health & Addiction Services (DMHAS), the patient's guardian, the local police department, the NJ Department of Health, and the NJ State Board of Nursing of the reported abuse of Patient #1 by Staff #11.

a. There was no evidence that the facility notified the NJ Division of Child Protection and Permanency (DCP&P) as per facility policy in Reference #3.

b. On 5/25/16, Staff #15 confirmed the facility did not report this event directly to the DCP&P.

Based on staff interview and review of facility documentation, it was determined that the facility failed to ensure its minimum requirement for staffing in the Psychiatric Intervention Program (PIP) is met.

Findings include:

1. In interview on 5/24/16, Staff #2 stated that the PIP unit is staffed with one (1) RN to four (4) patients. It is an eleven (11) bed unit, and there are three (3) caregiver RNs, and one additional RN is Team Leader (TL) /Charge, and we staff with two (2) BTs.

2. On 5/24/15, the 'PIP DAILY STAFFING SHEET' and the 'PIP DAILY TRACKING LOG' for Thursday 5/12/16 and Sunday 5/15/16 was reviewed.

a. The PIP Scope of service was requested from and received by Staff #2. The document titled '--[facility name]-- Provision of Care Plan for Patient Services 2015' indicates the Minimum staffing patterns are as follows:
Day Night
RN (4) RN (3)
MHS (2) MHS (1)
BT (2) BT (2)
1 Consumer Advocate
1 Administrative Assistant

b. The day-shift of 5/15/16, the PIP Unit had (4) RNs [3 of which were also MHS'], and (0) BTs. The PIP Unit was short staffed (2) BT's.

Based on a review of facility policy, medical record review and staff interview, it was determined that the facility failed to implement all policies and procedures governing the medical care of patients in the emergency service.

Findings include:

Reference #1: Facility policy titled "Emergency Department Triage" under Policy states, "Category 2 patients are considered a "high risk" situation, have new onset mental status change, behavioral problems reflecting the potential for harm to self or other, or are a flight risk, or are in severe pain/distress."

Reference #2: Facility policy titled "Patient Care and Safety in the Psychiatric Intervention Program (PIP)" under Procedure states, "Following medical clearance, patients are admitted to the Psychiatric Intervention Program (PIP) ..."

1. Documentation in Medical Record #3 revealed the following:

a. The triage intake note, dated 5/12/16 at 1:28 AM states, "pt arrived by bls, with police, was in middle of street, not cooperating or acting appropriately."

b. The nursing note, dated 5/12/16 at 2:19 AM states, "Patient was brought to PIP after being found lying down in the street by the --- (name of town) bus station. He was brought in 4 point restraints because he refused to cooperate ..."

c. The ESI level was documented as a four (4).

d. As per policy, the patient was a high risk related to behavioral problems and should have been an ESI level 2, as indicated in Reference #1.

e. There was no documentation of the patient being medically cleared before being admitted to the PIP unit.

f. As per policy, the patient should have been medically cleared as indicated in Reference #2.

2. The above was confirmed by Staff #7.