HospitalInspections.org

Based on facility policy, medical record review, video and interviews it was determined the facility failed to protect and promote patients' rights in one (Patient #1) of one patients reviewed for injuries. After being assaulted by hospital staff (Refer to A0145) and, after receiving treatment for injuries sustained in the incident patient was placed back into the care of the assailant (Refer to A0144).

Based on interview and record review, the hospital failed to ensure patient care was in a safe setting for 1 of 1 patients (Patients# 1) reviewed for abuse.

The findings included:

This hospital is a mental health facility. On 10/11/2022 at 2:00PM a review of patient #1 medical record revealed the following:
1. On 6/14/2022 at 4:00PM, Patient #1 was admitted to the facility with a diagnosis of psychosis.
2. On 6/23/2022 at 10:45PM patient required redirecting due to behavioral issues. Staff #A, a behavioral health tech grabbed Patient #1 and lifting him off the ground and threw him to the floor on his head and immediately walked away. Other medical staff can be seen immediately rendering aid to which 911 was called and patient #1 required transfer to another facility for treatment.
3. On 6/24/2022 at 0410AM the patient was discharged from the acute care hospital and back to the facility and into the care again of Staff A. Discharge paperwork stated the following diagnosis: closed head injury, multiple rib fractures (6), Scalp hematoma, scalp laceration requiring sutures.

In an interview with Staff D (unit manager) on 10/12/2022 at 12:00PM, she revealed she received a text message about the incident from Staff A on 6/24/2022 at 0640AM but was unable to address it immediately until 7 hours later. She further revealed she reviewed the incident via video footage, and on 6/24/2022 at 3:00PM Staff A was placed on administrative leave, 16 hours and 15 minutes after the incident.

On 10/12/2022 at 11:15AM an interview with Staff E (RN in charge of shift of that unit) confirmed he did not remove Staff A from the floor or from the care of patient #1, or other patients on the unit, nor was law enforcement or the abuse hotline notified.

Review of staff A personnel record reveals on 6/28/2022 staff A was terminated, report states' "Client is body slammed to the ground." "seen on camera not using proper TEAM (takedown) technique.'"

Based on record review, policy review, video review and staff interview it was determined the facility failed to ensure patients are free from all forms of abuse or harassment in 1 (#1) of 1 patient sampled.

Review of the Facility Policy Titled: Protection form Abuse, Neglect and Exploitation, Reviewed: 9/2021 revealed ....
Purpose: to provide a consistent method for the timely and accurate reporting of known or suspected cases of abuse, neglect, or exploitation against any person ....

Policy:
A. no individual served by Centerstone, will be subject to physical or verbal abuse by an employee.
B. In compliance with Florida statute sections: 39.201; 394.459(5); 395.1023; 415 and Florida administrative code 59A-3.280; 65E12.106 (2) (b)5; and 45 CFR; Parts 160 and 164, it is Centerstone policy to require every employee to report any knowledge, suspicion or reported information from others of abuse ...

On 10/11/2022 at 2:00pm a review of patient #1 medical record revealed the following:
1. On 6/14/2022 at 4:00PM, Patient #1 was admitted to the facility with a diagnosis of psychosis.
2. On 6/23/2022 at 10:45PM patient required redirecting due to behavioral issues. Staff A, a behavioral health tech grabbed Patient #1 and lifted him off the ground and threw him on the floor on his head and immediately walked away. Other medical staff can be seen immediately rendering aid to which 911 was called and patient #1 required transfer to an acute care facility for treatment.
3. On 6/24/2022 at 0410AM, the patient was discharged from the acute care hospital and back to the facility and into the care again of Staff A (who had injured the patient). Discharge paperwork stated the following diagnosis: closed head injury, multiple rib fractures (6), Scalp hematoma, scalp laceration requiring sutures.

In an interview with Staff D (unit manager) on 10/12/2022 at 12:00PM, she revealed she received a text message about the incident from Staff A on 6/24/2022 at 0640AM but was unable to address it immediately until 7 hours later. She further stated that she reviewed the incident via video footage, and on 6/24/2022 at 3:00PM Staff A was placed on administrative leave.

Review of staff A personnel file states on 6/28/2022 staff A was terminated, report states "Client is body slammed to the ground." "seen on camera not using proper TEAM (takedown) technique.'"

Interveiw with #G reveals that on 6/28/2022 Patient #1 was discharged from the facility . He immediately went to [a different acute care hospital] emergency department. Upon evaluation it was revealed Patient #1 had 6 fractured ribs, a fractured clavicle, scalp with sutures. Patient #1 stated he received these injuries as a result, of being assaulted by facility staff at Centerstone Behavioral Health.

An interview with staff B on 10/11/2022 at 11:30 AM, revealed that on 7/5/2022 DCF (Department of Children and Families) and Law Enforcement entered to facility to investigate the matter. She further stated that staff A had been charged with assault by law enforcement.

On 10/12/2022 at 11:15am interview with E (RN in charge of shift of that unit) confirmed he did not remove Staff A from the floor or from the care of patient #1 or other patients on the unit nor was law enforcement or the abuse hotline notified.

Video footage evidence obtained.