HospitalInspections.org

Based on facility policy review, medical record review, review of facility investigation, review of a police department Incident Report, observation, and interview, the facility failed to ensure the right to care in a safe setting for one patient (#1) of five sampled patients.

The findings included:

Review of facility policy titled "Abuse; Abandonment; Neglect; Exploitation - Detection of" most recently reviewed March 16, 2012, revealed, "...Cases of possible abuse...are reported to the appropriate agencies according to applicable law and regulation...Implementation: All associates, residents, visitors are encouraged to report incidents of patient abuse or suspected incidents of abuse...Gather and safefuard valid legal evidence...for the proper authorities...Associates will be instructed to observe for, intervene in, and report any incidents of abuse or neglect...An event report should be completed. The Risk Manager and Administrator-on-call must be notified immediately...supervisor will immediately begin an investigation of the reported incident...If the alleged abuser is another patient...Notify security immediately...Security will investigate and report to appropriate law enforcement agencies..."

Review of facility policy titled "Department Safety" most recently reviewed January 31, 2013, revealed, "...It is the policy of the Inpatient Behavioral Service Unit to adhere to the hospital wide safety policies and procedures...All hallways and common areas...have cameras that are monitored from the nurse's station...Police officers that enter the unit must leave their firearms outside the unit in a secure location...Security will be notified to secure the firearm..."

Medical record review revealed the patient (#1) was evaluated in the facility's Emergency Room (ER) on October 7, 2013, and admitted to the facility on October 7, 2013, with diagnoses including Mixed Dementia with Behavioral Disturbance.

Medical record review of an ER History and Physical dated October 7, 2013, revealed, "...has been using (anti-anxiety medication) 4 times a day as needed for agitation and this was relatively ineffective...falling a lot recently..."

Medical record review of a Master Treatment Plan dated October 7, 2013, revealed, "Patient will remain safe at all times...Initiate every 15 minute checks..."

Medical record review of a nurse's note written by Registered Nurse (RN #5) dated October 13, 2013, at 1:50 p.m., revealed, "Pt (patient) was in hallway with...granddaughter, yelling. (Patient #2) observed licking pt's hand. Pt's grand-daughter stated (Patient #2) grabbed...(patient's) groin area. Staff was able to instruct (Patient #2) to let go of (patient's) hand, which (Patient #2) did. (Patient #2) then proceeded to walk down the hall. (Patient #1) was then assisted to...room by this writer, (Licensed Practical Nurse - LPN #1), as well as...grand-daughter, and checked for injuries. No injuries noted. House Supervisor...(and Advanced Practice Nurse Practitioner - APRN) notified..."

Medical record review revealed Patient #1 was discharged from the facility on October 13, 2013, by family request and on order of a physician.


Review of the facility's investigation revealed the following:

Investigation report #1 dated October 13, 2013, and signed by RN #5: "...Time (1:50 p.m.) in hallway with...granddaughter...(Patient #2) observed licking pt's hand...granddaughter stated male patient grabbed (Patient #1's) groin area..." Continued review revealed the sections of the Event Report titled "If someone directly involved, please complete" and "If any witnesses, please complete" were blank.

Investigation report #2 dated October 13, 2013, and signed by RN #2: "Client (Patient #2) walking in hallway when encountered (Patient #1) walking in hallway with...granddaughter. Client proceeded to grab (Patient #1)...in the groin area. The granddaughter was unable to get (Patient #2) to let go so started yelling for help. Client did let go...(RN #5), (LPN #1), (Unit Clerk), (RN #7), (RN #6) responded to call for help...supervisor...APRN...notified (2:00 p.m.)..."

Investigation report #3 signed by RN #6: "(Date, time, and location of event were blank.)...What happened? This writer sitting in nurse's station, heard someone yell for help. Upon entrance to Geriatric hallway, this writer observed male pt. standing against left wall, (Patient #1) and granddaughter standing against right wall, granddaughter reported that male pt grabbed (Patient #1's) private area. After seeing situation was stable...went back to nurse's station..." Continued review revealed the sections titled "If someone directely involved, please complete" and "If any witnesses, please complete" were blank.

Investigation report #4 signed by RN #4:
"Date of Event 10-13-13 Time: (blank)...What happened? Called to (Inpatient Behavior Unit) about a patient situation. Upon arrival at the elevator doors is a KPD (Knoxville Police Department) officer and our security officers along with a (unit) nurse. Was informed about the situation and immediately paged (unit's clinical leader), Risk Management...Administrator-on-call...and also (unit's Executive Director)...a Knox County Detective had also arrived wanting statements from the nurses. The daughter and grand daughter of...the patient that was assaulted was giving the detective their side of the story...After talking with (managers) we decided to let the detective know that we would get back with them Monday morning (next day) with whatever information they needed to know..."

Review of a facility report dated October 21, 2013, revealed, "...Date of Occurrence: 10/13/2013...staff heard someone call out 'Help.' The staff immediately responded to the hallway and saw a male patient 'licking' (Patient #1's) hand. The nurse told the patient to stop...dropped hand and was easily redirected to continue down the hallway...The granddaughter then told the staff that...(Patient #2) was walking past her and (Patient #1) and suddenly 'grabbed' (Patient #1's) groin area...A skin assessment of the groin area was completed by the 2 nurses with the assistance of the granddaughter. No red areas, bruises or abrasions were noted..."

Review of the facility's investigation revealed no witness statement from Patient #1's granddaughter.

Security department narrative: "...10/13/2012...At approximately (4:20 p.m. - more than two hours after the incident) Security was requested to respond...to discuss a situation...arrived to find...Police Department Officer (#1)...speaking with the daughter and granddaughter of patient (#1) in...elevator lobby...family member were explaining a situation...regarding an incident that had occurred between (Patient #1)...(and Patient #2)...At that time...(RN #4) arrived to assist...(RN #2) stated that (Patient #2) had grabbed (Patient #1) in a sexual manner..."

Review of a police department Incident Report dated October 13, 2013, revealed, "...Brief Description of Incident Forcible Fondling - (Patient #1)...On 10/13/2013 at (4:30 p.m.), I (Police Investigator #1) responded to a Forcible Fondling at (facility)..." Continued review revealed, "...Title: Supplement...Upon arrival I spoke with (Police Officer #1) who was the first responding officer and...(Patient #1's granddaughter) who stated she witnessed the assault...(Patient #1's granddaughter) notified the police..."

Observation of a security camera monitoring screen with the Executive Director of the unit at the nurse's station on October 28, 2013, at 1:37 p.m., revealed the screen displayed nine images of activity on the unit, included three images of the gero-psych unit hallways, and no staff monitored the screen.

Telephone interview with Patient #1's granddaughter on October 23, 2013, at 2:18 p.m., revealed Patient #1 had Alzheimer's Disease. She stated, "...I was walking (Patient #1) down the hall...(Patient #2) was walking in opposite direction. Next thing I know (Patient #2) grabbed (Patient #1) by...breasts...squeezed so hard and grabbed...(groin area). When (Patient #2) went for those areas...knew specifically what (Patient #2) was doing...trying to get clothing off (Patient #1) but I intervened. The more I worked at keeping (Patient #1) from falling the more force (Patient #2) put on (Patient #1). No one else was in view. I wedged myself between them. The point (of wedging self) was (to) try to keep...genital area away... It ended when I could not fight (Patient #2) off. I screamed for help and lots of nurses came..."

Interview with the unit's Executive Director on October 28, 2013, at 1:37 p.m., at a nurse's station, revealed the facility did not assign staff to monitor the images from the security cameras.

Interview with RN #2 on October 28, 2013, at 1:45 p.m., at a nurse's station, revealed RN #2 was at the nurse's station on October 13, 2013, heard a scream, and responded to the scream. Continued interview revealed Patients #1 and #2 were located approximately twenty feet from double doors at the end of the gero-psych hallway opposite Room T414. RN #2 stated, "...When I got out here the patient (#1) and granddaughter were here. The male patient was told to let go of (Patient #1's) hand. I did not see any touching for either patient." Continued interview revealed RN #2 had not observed Patient #2 demonstrate inappropriate behavior.

Telephone interview with Licensed Practical Nurse (LPN #1) on October 28, 2013, at 2:35 p.m., revealed, "...was in nurse's station...heard scream for help...went toward scream...What I saw the patient (#2) had...(Patient #1) by the hand. I think (Patient #2's) mouth was on (Patient #1's) hand. The granddaughter had (Patient #1) in protective hold pushing...(Patient #2) back and telling (Patient #2) no...(Granddaughter) said, '(Patient #2) grabbed (Patient #1's) privates'...hands were on (Patient #1's) hands. I got between her and (Patient #1). Other employees came. Area (was) very near the geri (gero-pscyh) day room. It was not close enough for the staff to see...(RN #5) came...I did not see (Patient #2) grab (Patient #1)..." Continued interview revealed LPN #1 had not observed Patient #2 demonstrate any inappropriate behavior before the events of October 13, 2013, and had not completed an incident report or been interviewed as part of the facility's investigation.

Interview with the facility's Risk Manager on October 28, 2013, at 12:30 p.m., revealed RN #4's event report was considered the facility's documentation of the event of October 13, 2013, required by the facility's abuse policy.

Telephone interview with RN #4 on October 28, 2013, at 2:08 p.m., revealed, "That night I was house supervisor...Maybe an hour into the shift I got call from...(RN #2)...I got off elevator, security was there with...police officer. The granddaughter and her mother were there...I told (RN #1-unit's clinical leader) I had officer outside and she told me officer was not allowed in unit...called Administrator-on-call...I filled out an incident report and got several people to fill out incident reports...We look at monitoring screens at times...I had no first hand observation of this incident between the patients."

Interview with the facility's Risk Manager on October 28, 2013, at approximately 2:30 p.m., in an administration conference room, revealed all staff involved in the events of October 13, 2013, had not been interviewed and the facility's investigation remained incomplete.

Telephone interview with RN #5 on October 29, 2013, at 1:15 p.m., revealed RN #5 saw Patient #2 lick Patient #1's hand. RN #5 stated, "...I was in the day room...(Patient #1) was yelling. (Patient #2) was bent down licking (Patient #1's) hand...was told to stop. At that point there was three to four staff already there. Initial yelling I would say was (Patient #1's) granddaughter. Both patients were standing. I did not see (Patient #2) do anything else to (Patient #1)...Granddaughter only said he grabbed...groin area. From what I saw and heard my nurse's note (October 13, 2013, at 1:50 p.m.) is correct. Other staff there when I showed up - (RN #2)...(Unit Clerk)...(RN #6)...and (RN #7)...staff were just calling for (Patient #2) to stop. (Patient #2) just walked down the hallway. (LPN #1) was another nurse who went to patient's (#1) room with (Patient #1)...did not see any staff pull (Patient #2) away from (Patient #1). I completed an incident report on both of them because they were my patients..."

Interview with the unit's Executive Director on October 29, 2013, at 8:55 a.m., in an administration conference room, revealed the facility had failed to thoroughly investigate the allegation of abuse in a timely manner according to facility policy. Continued interview confirmed the facility failed to follow facility policy to ensure Patient #1 was provided care in a safe setting on October 13, 2013.