HospitalInspections.org

Based on a review of the facility's policies/documents, medical record (MR) and interview with staff (EMP), it was determined that the facility failed to ensure the development and maintain comprehensive policies and standards for assuring the safety of patients.

Findings include:
On July 5, 2022, review of the facility's Medical Staff Bylaws effective October 14, 2021, revealed, "5.D Medical Executive Committee- 5.D.2. Duties: The MEC is responsible for the following: (b) (7) (i) reviewing or delegating to the Bylaws Committee the responsibility to review, at least once every five years, the Bylaws, policies, Rules and Regulations, and associated documents of the Medical Staff and recommending such changes as may be necessary or desirable."
On July 5, 2022, review of facility's Patient Injury policy with effective date of June 29, 2022, and origin date of September 1989 revealed, "POLICY- Occurrences involving either a custodial related patient injury or an iatrogenic (medically related) injury require immediate investigations at the facility as well as prompt reporting to the PA Department of Health and the organization liability insurance representative. PROCEDURE 2. The patient's family is notified by a member of the treatment team."
Request made for documentation family was notified of incident no documentation was received. Request for a Patient Assault by staff policy was requested no policy was received.
Interview with EMP2 on July 5, 2022, EMP2 confirmed there is no documentation family was notified of incident. EMP2 also confirmed there is no Physical assault by staff policy and the Patient Injury policy had not been reviewed since September 1989 and prior to the incident.

Based on a review of the facility's policies, documents (video coverage), medical record (MR) and interview with staff (EMP), it was determined that the facility failed to ensure a patient seeking psychiatric emergency services was free from abuse from the facility's staff for one of one medical record reviewed (MR1).

Findings include:

On July 5, 2022, the surveyors arrived at the facility for the unannounced investigation. Entrance conference was completed with EMP1, EMP2, EMP3 and EMP4. A facility tour of Emergency Department (ED) was initiated with EMP1 as the guide.

On July 5, 2022, review of facility's Crisis Prevention Institute (CPI) training model noted from the facility's Workplace Violence Prevention Plan with effective date June 2021 revealed "Safety Interventions-Disengagement Skills: The Purpose of disengagement is to keep yourself and others safe from injury when you are confronted with risk behavior. You will practice a range of physical interventions which are designed to maximize safety and minimize harm. - Key Themes to Consider with Physical Intervention: Duty of care (actions and omissions to do no harm) with the best interest of the person in crisis ... Physical interventions must be the last resort and least restrictive ... You are obligated to reduce use and prevent the misuse and abuse of physical interventions ..." Photo observed in training model of an individual using a blocking intervention from another individual who appears to be throwing a punch.

During Interview with EMP6 on July 5, 2022, at 11:05 AM, EMP6 confirmed completing CPI training and stated the physical interventions taught during the training was to use arms/hands for blocking motions and not to put arms/hands in forward motion as if striking an individual. EMP6 also stated and exhibited how during blocking hands are to be open and a closed fist should not be displayed.

On July 5, 2022, review of facility's Patient Injury policy with effective date of June 29, 2022, and origin date of September 1989 revealed, "POLICY - Occurrences involving either a custodial related patient injury or an iatrogenic (medically related) injury require immediate investigations at the facility as well as prompt reporting to the PA Department of Health and the organization liability insurance representative. PROCEDURE 2. The patient's family is notified by a member of the treatment team."

Request made for documentation family was notified of incident, no documentation was received. Request for a Patient Assault by staff policy was requested, no policy was received.

Interview with EMP2 on July 5, 2022, EMP2 confirmed there is no documentation family was notified of incident. EMP2 also confirmed there is no Physical assault by staff policy and the Patient Injury policy had not been reviewed since 1989 and prior to the incident.

Review of MR1 on July 5, 2022, ED summary note entered by EMP7 on June 18, 2022, revealed "At approximately 255 patient became agitated aggressive and was throwing punches at two staff members in the emergency department causing abrasions and contusions and there [sic] need to be evaluated by me the patient was punched in the right eye suffering an abrasion contusion ..." Review of Computed Tomography (CT) scan of Maxillofacial without contrast report signed by EMP8 on June 18, 2022, at 8:12 AM revealed, "Report History: Patient Assaulted Impression: Depressed right orbital floor fracture with right orbital proptosis. Right periorbital soft tissue swelling."

Review of facility video surveillance revealed patient in an agitated crisis event swinging at EMP5 and EMP8, as EMP8 is trying to get patient in control, EMP5 pulls right arm back and punches patient in the face with a closed fist then turns and exits the room. As the patient falls back and down EMP8 can be seen trying to assist the patient seconds later other staff members come in to assist EMP8. It appears that patient is bleeding from the face.

During interview with EMP1 on July 5, 2022 EMP1 confirmed EMP5 punched the patient in the face in a manner that is not in line with the CPI training provided to staff.