HospitalInspections.org

Based on observation, interview, record review, and policy review the facility failed to:
- Adequately protect one patient (#10) of 11 patients on the Intensive Treatment Unit (ITU - a psychiatric unit for patients with aggressive or behavioral issues) from physical and verbal abuse. (Refer to A-0145)
- Follow their internal policies on Code White; Restraint/Seclusion and Patient Abuse and Neglect. (Refer to A-0145)
- Protect one of one patient (#10) from an Alleged Perpetrator (AP), following an abuse event. (Refer to A-0145)
- Conduct a timely investigation following an abuse event which resulted in the failure to implement corrective action to prevent any future abuse. (Refer to A-0145)
- Protect two current patients (#2 and #11) from neglect and verbal abuse and one discharged patient (#9) from verbal abuse or threats which were punitive in nature. (Refer to A-0145)

These failures had the potential to affect all patients at risk of abuse in the facility. The facility census was 339 of which 73 patients were considered at risk for abuse in the psychiatric units.

The cumulative effect of these systemic practices had the potential to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ).

On 09/17/14, after the survey team informed the facility of the IJ, the staff created educational tools and began educating all staff and put into place interventions to protect patients.

As of 09/18/14, at the time of survey exit, the facility had provided an immediate action plan sufficient to remove the IJ by implementing the following:
- Staff HH, RN, charge nurse, who choked the patient was terminated on 09/17/14.
- Staff MM, RN, House Supervisor, who failed to intervene on the patient's behalf or report the event was terminated on 09/17/14.
- The police department was notified by the facility and responded on 09/18/14.
- All psychiatric nursing staff were re-educated on the expectations of mandated reporting of abuse before resuming the care of patients on the psychiatric units.
- All House Supervisors were educated on their role expectations to include identifying abuse, oversight of Code White (a multi-disciplinary team response to evaluate and intervene when a patient, family member or visitor is exhibiting a behavioral crisis, or potentially disruptive, inappropriate or threatening action(s) that compromises the safety and well-being of themselves and/or others) and restraint episodes, to lead and direct the employees, to remain at the event and manage the situation, and immediately report events to the administrator on call.
- All psychiatric Senior Leadership Administration, Leadership of Security and Emergency Services were re-educated on the Patient Abuse and Neglect Policy, Mandated Reporting Policies and CPI (Crisis Prevention Institute) techniques.
- Additional training and education was provided to all staff on psychiatric units on the use of patient privileges used punitively for disciplinary action.
- Additional training and education was provided to nursing staff on patient assessments while in restraints, documentation in restraints and event reporting.
- Concentrated training was provided to all psychiatric staff on NVCI(Non-violent Crisis Intervention)/CPI de-escalation techniques with a certified CPI Trainer.
-The facility revised multiple policies including the Code White Policy and procedures and terminated employee badge access procedures.
- Unannounced mock Code White drills were implemented on an ongoing basis to include all shifts.
-The facility created, approved and posted a new safety tech (technician) role for the Adult/ITU and will hire for the position by 09/24/14. The role is designed for the behavioral health (psychiatric) units to manage the milieu (a physical or social setting), continually round on patients and be the team lead for Code White.
- An external Peer Review will be completed for Staff U, Psychiatrist, attending physician, and his participation in the event.
- Senior Leadership and psychiatric unit's management will round on current patients multiple times daily to ensure continued safety, address patient concerns and encourage feedback on care.
- All Code Whites will be reviewed by Senior Leadership by the next business day to ensure the policy and NVCI/CPI techniques have been utilized correctly. The review will include review of the documentation and videotapes on the psychiatric units. All Code Whites will be tracked and trended on an ongoing basis for occurrence and appropriate documentation. This will be reported to the Quality Committee monthly.





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Based on observation, interview, record review and policy review the facility failed to protect one patient (#10) of 11 patients in the Intensive Treatment Unit (ITU - a psychiatric unit for patients with aggressive or behavioral issues) from abuse by strangulation using a Rear Naked Choke (a submission hold used in mixed martial arts that cuts off the flow of blood to the brain. If applied correctly, it will force the opponent to submit. If they do not submit, they will pass out within a matter of seconds), verbal abuse and protection from an Alleged Perpetrator (AP), Staff HH, Registered Nurse (RN). The facility also failed to protect two current patients (#2 and #11) and one discharged patient (#9) from neglect (the failure to maintain reasonable care and treatment of an individual to the extent well-being is injured) and/or verbal abuse (use of threats or harsh words). These failures put all patients at risk for abuse and violation of their basic patient rights. The facility census was 339 and the census on the psychiatric units was 73.

Findings included:

1. Record review of the facility's policy titled, "Patient Abuse and Neglect," revised 03/14, showed the following direction to staff:
- To inform all employees of the policies and procedures of the facility regarding the rules, regulations and consequences pertaining to alleged patient abuse and immediate actions to be taken subsequent to a report or suspicion related to patient abuse.
- Patient abuse, neglect, or exploitation by employees, affiliates, and agents of the facility is prohibited, and shall be grounds for disciplinary action up to and including termination.
- It is the responsibility of all employees and health care providers employed by or affiliated with the facility who may witness, suspect patient abuse or to receive report of same from the patient, their family or other staff to report this suspected abuse and/or neglect to their supervisor immediately. This can include physical, sexual, emotional, verbal and/or social abuse.
- Any health care provider whom knowingly fails to make an abuse report may have criminal liability.
- Upon receipt of an allegation of suspected abuse and/or neglect, it is the responsibility of the Department Director or House Supervisor to initiate investigation of the situation and place on administrative leave, any staff that are suspected to have committed an act of abuse or neglect until a determination is made. This allows time to conduct an investigation, while keeping in mind the protection of the patient, the facility and staff involved and initiate the patient grievance process.
- Abuse is the intentional infliction of injury (i.e., punching, slapping, biting, pushing, kicking, attempted strangulation), verbal abuse, sexual abuse, unreasonable confinement, fiduciary [person to whom property or power is entrusted for the benefit of another] abuse, intimidation, cruel punishment, omission or deprivation by a caretaker or another person of goods, services which are necessary to avoid physical or mental harm or illness.
- Verbal Abuse is language used to manipulate, control, ridicule, insult, humiliate, belittle, vilify, and show disrespect and disdain to another which hurts the listener and is not accidental.
- The Department Director/House Supervisor has the independent authority to immediately place the employee on administrative leave pending resolution, and results of the abuse investigation.
- The Department Director/House supervisor will immediately notify the Administrator on Call and Security of the allegation for further assistance and guidance as needed.
- Reports of suspected abuse or neglect will be referred to the appropriate agencies within 24 hours of determination.

Record review of the facility's Policy titled, "Code White," revised 03/14, gave the following direction to staff:
- To provide a multi-disciplinary team approach to evaluate and intervene when a patient, family member or visitor is exhibiting a behavioral crisis, or potentially disruptive, inappropriate or threatening action(s) that compromises the safety and well-being of themselves and/or others.
- Behavioral management of the crisis situation will be conducted in a manner that utilizes the least restrictive environment possible to provide care, welfare, safety and security of all those involved in the crisis situation.
- Patient Care Services with current competency training in non-violent crisis intervention shall respond to all crisis situations which will be called Code White campus wide. The Security staff will respond per campus specific practices.
- Employees with direct responsibility for therapeutically managing crisis situations, shall be certified in NVCI [Non Violent Crisis Intervention] at the start of employment and biannually.
- Purpose of the Code White Team [a multidisciplinary response team with current competency training in non-violent crisis intervention that responds to and has the authority to de-escalate behavioral situations involving disruptive, inappropriate or threatening behaviors that compromise the safety and well-being of others] is to assist a patient, family member or visitor to regain control of behaviors that place them or others at risk and to provide safety for the patient, family member, visitor, staff or other patients. To this purpose the team will provide staff backup; escort the patient, family member, visitor or employee to a safe area, using the least restrictive means; use seclusion when necessary for the safety of patients and others; apply restraints to provide safety for the patient and others; assists in the administration of emergency medications.
- Debriefing: Following the Code White the responders and involved staff are required to hold a debriefing event with the patient and with the team and involved clinical staff.
- Notifications: Following the Code White intervention and debriefing event the team lead will initiate a MediTech [name of computer software form] Notification and copy of the following individuals: Director and immediate supervisor of area; Medical team; Quality and Risk Manager; CNO [Chief Nursing Officer] or Administrator; Administrator on Call; Patient representative - Patient Safety; Social Services; Spiritual Care.
- Documentation and review of Code White events: Initial Responders: Team Lead will complete the Code White Event form following the event. This form will be maintained in a log book in Nursing administration. Primary caregiver: Will document the summary of events leading up to the event including behavioral triggers for the Code White in the patient's medical record. Secondary responders: Will document their interdisciplinary assessment, interventions and recommendations in the patient's medical record. Debriefing and recovery will occur immediately following the intervention. Written observations will be documented in the form.

Record review of the facility's policy/procedure guideline titled, "Alternatives to Restraints," revised on 04/14, gave the following direction to staff on Physical Holds: Holding a patient in a manner that restricts the patient's movement against the patient's will is considered restraint. This includes holds that some members of the medical community may term "therapeutic holds." Many deaths have occurred while employing these practices. Physically holding a patient during a forced psychotropic medication procedure is considered a restraint. If the patient is in a physical hold, a second staff person is assigned to observe the patient to ensure safety and the patient's airway is not compromised.

2. Record review of the facility's undated document titled, "Restraint/Seclusion," gave the following direction to staff on documentation for patients placed in restraints:
- Complete restraint documentation screens in MediTech for clinical justification; type of restraint; second tier review; monitor; least restrictive measures/alternatives/ notifications of family guardian; criteria for release; safety/dignity check.
- Change of condition note in MediTech - describe behaviors and least restrictive measures attempted;
- Debrief;
- Complete a notification in MediTech;
- Notify administrator and nurse manager on call for all restraint/seclusion events.

3. Record review of Patient #10's history and physical dated 09/05/14 showed he was a 27 year old male with a past history of bipolar disorder (a brain disorder that causes unusual shifts in mood, energy, activity levels), borderline personality disorder (a mental illness marked by unstable moods, behavior, and relationships), polysubstance dependence (addiction to more than one drug), self-harm (the practice of cutting or otherwise wounding oneself, usually considered as indicating psychological disturbance), and multiple suicide attempts (serious gestures of self-harm without the result of death).

4. During an interview on 09/16/14 at 9:55 AM Staff P, Chief Executive Officer of the Psychiatric Units, stated that an abuse event occurred on 09/07/14 but the administration did not learn of the event until 09/10/14 because it was not reported by Staff MM, HS, as required by policy and procedure. She stated that the AP, Staff HH, RN; Staff MM, House Supervisor (HS), were telephoned and put on administrative leave pending position termination and Staff NN, RN, was telephoned but resigned her position at that time. Staff P stated that a Root Cause Analysis and Action Plan were completed by Leadership Management on 09/15/14.

5. Record review of the facility's undated document titled, "Root Cause Analysis and Action Plan Framework Template," showed that the following events were precipitated by the removal of patio privileges (e.g. smoking privileges) as a result of a patient's poor behavior. These patient privileges were used in a punitive manner that caused Patient #10 to escalate (increase) his behaviors and began hitting the wall with his fist.

6. Observation on 09/16/14 at 10:10 AM showed a videotape (video) of the event on ITU on 09/07/14 at 5:26 PM with Staff HH, AP, RN, Charge Nurse; Patient #10; Staff Y, Mental Health Technician (MHT) and Staff NN, RN, Patient #10's primary Nurse. The video showed the patient going down the hall away from the camera and punching the wall with his right hand approximately 16-17 times. The three staff members were then seen walking side by side down the hall toward Patient #10. They moved in a line toward the patient backing him up to the wall. The patient broke through the line and started walking toward the camera when Staff HH jumped on the patient from behind and proceeded to get his right arm around the patient's neck and they hit the wall and then fell to the floor. Staff NN jumped over the patient and held the patient's right arm to the floor. Other staff responded to the Code White one at a time. Security did not respond to this event (and there were conflicting accounts if they were ever called to respond). Staff U, Psychiatrist, and Staff MM, RN, HS, were both seen in the videotape standing directly in front of the patient's head while Staff HH had the patient in a choke hold. Patients on the unit were seen walking up to and around the patient and staff without being redirected or moved to a safe area. The episode lasted approximately 13 minutes with the patient being held to the floor for approximately 12 minutes.

Observation on 09/16/14 at 10:30 AM of a second video dated 09/04/14 at approximately 5:57 PM showed another event occurred when Patient #10 jumped on top of the nurses' station counter and onto the floor inside the nurses' station. Staff HH then jumped onto the same counter and onto Patient #10's back with his right arm around the patient's neck, knocked over an intravenous (in the vein) pole and hit a medication cart before falling to the floor. The patient did not move at this point and other staff began to respond to the Code White and eventually Staff MM, HS, and Staff W, Security Specialist (Officer), responded. Other staff identified in the video were Staff Q, Plant Operations; Staff OO, RN; Staff PP, RN, and Staff Y, MHT.

7. Record review of the medical record for Patient #10 and the nurses' notes documented by Staff NN, RN, Patient #10's primary nurse, did not provide the required documentation for restraints.

8. During an interview on 09/16/14 at 10:30 AM, Staff R, Nurse Manager of ITU, stated that he had watched the video and was bothered that no one [staff] helped the patient. He stated that several staff and physicians had been injured in these kinds of events and they were just now getting started to change the milieu (social environment) of the ITU. Staff R stated that Staff HH was viewed by the female staff as their savior and cowboy and kept them safe. He stated that Staff HH, Staff MM and Staff NN were on administrative leave but were still employees of the facility. He stated that Staff HH called him at the facility on 09/08/14 and came in to talk with him about, "Some take downs that didn't go too well over the weekend." Staff R stated that they viewed the video of the event together and after the first event Staff HH stated, "If you think that is something, wait until you see the next one." Staff HH told Staff R the name of the choke hold on the patient and stated that, "He knew what he was doing" and occluded both of the patient's carotid arteries which caused him to pass out. Staff HH told Staff R that he then relaxed his grip on the patient until he began to regain consciousness and then applied the hold again to keep the patient down awaiting medication. Staff HH had an appointment with administration on 09/17/14. Staff NN was interviewed over the telephone about the event and resigned her position at that time.

9. Record review of Patient #10's undated verbal statement given to Staff R stated that the patient was asked to talk about the events that occurred on 09/07/14. "I don't agree with everything that happened, but I don't want to get anyone in trouble either. He [Staff HH] choked me out. I think he was scared. He came up a couple of times this week to see me. I told him I wouldn't report it. He was cussing at me. He said, "Go to sleep fucker" and he choked me out. I don't want him to get in trouble though. I think he did what he did because he was scared. My vision went black and I could see these colored dots flashing. I didn't know if he was going to kill me or what."

10. During an interview on 09/16/14 at 3:40 PM, Staff R stated that he was not aware that the AP, Staff HH, had visited Patient #10 after the event until Patient #10 told him. "It must have been after we watched the video together."

11. During an interview on 09/16/14 at 3:32 PM, Patient #10 stated that he liked the nurse that hurt him and that he had been there two times to talk to him since the event. Patient #10 stated that he remembered what happened to him and that he thought the nurse [Staff HH] was afraid and wanted to protect the girls, "I wouldn't hurt a girl, they haven't done anything to me that I haven't done to myself." Patient #10 stated that he was put in four point leather restraints after the event and that he broke the bed that held the leather straps holding his ankles and freed his legs. He stated that he was able to bite his hand removing the skin so he would be taken to the emergency room (ED).

12. Observation of Patient #10 on 09/16/14 at 3:32 PM showed a large five inch square bandage on his left hand.

13. Record review of the facility's emergency provider report dated 09/07/14 at 8:43 PM showed the patient presented to the ED with head pain, back pain and bilateral hand pain. The report showed:
- Patient transferred here from [the psychiatric unit] after biting skin off of his left hand and eating it. He then was tackled over a desk and stated he hurt his back during that time. He was then medicated and transferred to the ED.
- Head/eyes: Frontal hematoma [a collection of blood on the surface of the brain];
- Skin: Left hand with a five by five cm [centimeters] square laceration. There is no skin or the patient removed it. There is also a small one cm flap [of skin] with frayed edges. There is viable tissue present.
- Indication: Assault, hypoxia [reduction of oxygen supply to a tissue].
- Reason for exam: tackled at [psychiatric unit].

14. During an interview on 09/17/14 at 2:00 PM, Staff MM, RN, HS, watched the video of the events and stated, "I think he's [Staff HH] talking to him [the patient], isn't he?" Staff MM denied that she saw Staff HH's arm around Patient #10's neck during either encounter when she was present. She stated she didn't do a MediTech report (incident report of the event) because she didn't see anything wrong with the take down. Staff MM stated that she didn't know the patient was in a choke hold because she couldn't see his face. Staff MM stated that it didn't look like CPI was used by staff in the video. She stated that she called and talked with administration three times on the evening of 09/07/14 after the events but didn't report abuse of the patient or put Staff HH on administrative leave because she didn't know it was abuse until now.

15. During an interview on 09/17/14 at 1:05 PM, Staff HH, RN, stated that:
- Patient #10 had been denied a smoke break because he received a Geodon (antipsychotic medication used to treat schizophrenia and depression) injection prior to his smoke break causing his gait to be unsteady and staff was afraid he would fall.
- Patient #10 became upset because he could not have his smoke break and stated that it was his right and began to yell at staff.
- Patient #10 did not calm down after staff tried to calm him.
- Patient #10 walked down the hall and began punching the wall with his fists.
- Two female staff accompanied Staff HH down the hall where Patient #10 punched the wall with his fists.
- He called a Code White but facility security did not show up to help with the first incident when Patient #10 was taken down.
- He used a "rear carotid restraint or also referred to as a rear naked choke (sleeper hold)" that he had looked up and used for the first time on Patient #10 during the second take down when he became violent.
- He did not have permission from facility staff to use the "rear carotid restraint" on patients.
- During the second incident Patient #10 became very violent by picking up chairs and tables and throwing them.
- He did not feel what he did was abuse because of the behavior, violence and threats displayed by Patient #10 towards female staff.
- Patient #10 did experience approximately an eight second period loss of consciousness while in the "rear carotid restraint".
- He never received debriefing from staff after a patient had been taken down or restrained to see what worked or what did not work during the incident.
- Staff never told him what needed to be improved or changed during a take down or use of restraints.
- He was not sure what the facility's policy and procedure was related to restraints.
- Staff HH, stated, "How do you expect someone like me to take him down?" (On admission to the facility the patient measured 6 feet tall and weighed 319 pounds.)

16. During an interview on 09/24/14 at 1:38 PM, Staff NN, RN, stated that she was the primary nurse for Patient #10 on 09/07/14. She stated that the patient had three different outbursts that evening and had verbally threatened staff and peers. She stated that she had watched the video of the incident where Staff HH held Patient #10 down. She stated that she did not see Staff HH choke the patient but he was rougher with him than usual. She stated that those events happened a lot and it took security 20 plus minutes to respond to her calls that evening. She stated that she resigned her employment because the staff are constantly put in very unsafe situations and the facility never fixed the problem.

During an interview on 09/17/14 at 2:35 PM, Staff V, Environmental Services, stated that:
- He responded to the Code White for Patient #10 on 09/07/14.
- He saw the arm of Staff HH around the patient's neck but did not intervene on the patient's behalf.
- What he observed was not the appropriate way to "take down" a patient.
- He would not "take down" a patient the way Staff HH did and the hold he had on the patient was inappropriate.
- He has had no education regarding the events.

During an interview on 09/17/14 at 2:50 PM, Staff W, Security Specialist, stated that:
- He did not get a call to respond until the second event on the evening of 09/07/14 and Patient #10 was already on the floor in the nurses' station when he arrived.
- He stated the "patient was talking but the RN's arm was around his neck and I encouraged him to let him up and I backed away from the situation."
- He asked staff on the unit what needed to be done and staff informed him that Patient #10 needed to be moved to the "quiet" room.
- The hold on the patient was not a typical way to hold or restrain a patient.
- He had not seen staff use that kind of "hold" on a patient before and he would not have used the same technique that Staff HH used.
- He would never use a "choke" hold because he is not trained in that technique or type of hold.
- It would not be his expectation to see staff with their arm around a patient's neck.
- He would report anything related to abuse and neglect to his supervisor and he would notify the local police department.

During an interview on 09/18/14 at 9:15 AM, Staff BB, MHT, stated that she responded to the second Code White for Patient #10 on 09/07/14. She stated that Staff HH was lying on top of the patient when she arrived and she knelt down to take the patient's hand when he stated to her, "He [Staff HH] is making me mad, get him off of me."

During an interview on 09/18/14 at 10:00 AM, Staff U, Psychiatrist, stated that he was present at the first event but not at the second event. He stated that he did not see Staff HH's hands at the time but gave verbal orders for medications. Staff U stated that he was paged after the second event at 5:58 PM with Patient #10 and never saw or witnessed the event. He stated that he gave a telephone order for restraints because the medication was not de-escalating (to decrease or diminish the intensity of the episode) the patient and he was out of options. He stated that he did a face-to-face assessment while the patient was in restraints and assessed the injury to his hand and called 911 to transfer the patient to the ED for treatment.

During an interview on 09/17/14 at 2:20 PM, Staff X, RN, stated that:
- Several "codes" were called that day that included Patient #10.
- She observed Patient #10 down on the floor at the nurses' station.
- If she had seen staff using a "choke" hold on a patient it would be inappropriate and she would not think it was a proper way to handle a patient's behavior.
- She did not feel like that kind of force is ever needed and she would never personally take a patient down physically but would seek help from other staff.

During an interview on 09/17/14 at 3:30 PM, Staff Y, MHT, stated that:
- She knew Patient #10 and had provided 1:1 (one staff member provides constant observation) observation for him in the past.
- She held Patient #10's arm during both holds.
- Patient #10 had became very upset when staff would not let him have his smoke break because he had received medications earlier and Patient #10 had reported to staff he had fallen.
- Patient #10 became very threatening to both staff and peers.
- Staff HH was yelling profanity at Patient #10 while he had him in a choke hold.
- She used the proper CPI hold on Patient #10 but did not feel like Staff HH used proper hold techniques.
- "She rubbed Staff HH's arm a couple of times and asked him to calm down and he did relax his hold on the patient's head slightly."
- She did not report the incident of Staff HH's improper "hold" because the house supervisor, charge nurse and Patient #10's physician were present during both take downs.
- She was instructed by staff not to document the two incidents with Patient #10.
- She tried to encourage Staff HH to calm down because Staff HH and Patient #10 were both verbally going at each other.
- No one followed up with her and to her knowledge there was no debriefing after the two incidents with Patient #10.

During an interview on 09/17/14 at 1:15 PM, Staff O, Medical Director, stated that:
- He was aware of the event that occurred on 09/07/14 and had watched the video recording.
- He understood that Staff HH, RN, had requested additional medication to be given, or for an increase to the dosage of the medication injection used for Patient #10.
- All of the available oral medications and as needed medication injections had been utilized for the patient.
- Patient #10 needed to be talked to, he was escalating.
- He was concerned related to the force utilized by Staff HH.
- Communication regarding escalating patients needed to improve.
- Any number of staff present at the time of the incident should have asked Patient #10 be restrained in a different way.
- If the staff were involved in this event again they would have Staff HH remove his arms from around Patient #10's neck.

During an interview on 09/17/14 at 1:28 PM, Staff Q, Plant Operations, stated that:
- He responded to the Code White on the ITU on 09/07/14.
- Staff Q had not had de-escalating technique training (CPI) for approximately four years, and he routinely assisted with patients who were escalating.
- He observed Staff HH, RN, have his arm around the upper part of Patient #10's body (neck/shoulder area).
- The patient verbalized to Staff HH to let him go.
- Staff HH responded not until he calmed down.
- This was not usual procedure for "take downs". Usually staff held patient's extremities down, not the upper part of the patient's body (neck/shoulder area).

During an interview on 09/17/14 at 2:15 PM, Staff Z, RN, stated that:
- She was working on the Adolescent unit on the day of the event and that she responded to the Code White on the ITU.
- She observed staff and Patient #10 on the floor.
- Patient #10 had yelled and cursed at the staff.
- The physician was there and gave an order for a medication.
- She obtained necessary papers from the computer for the House Supervisor.
- She had heard staff tell patients they could not go out and smoke as a punitive measure on the Adult unit.
- The patients on the ITU were not allowed to go out and smoke.

17. Record review of the facility's policy titled, "Patient Abuse and Neglect," revised 03/14, showed the following:
- The use of verbal or other communication to curse, vilify, or degrade a patient; threatening by words or actions with physical harm, or intent to inflict physical injury is considered a Class III abuse.
- Examples of verbal abuse include yelling, threatening, swearing.
- This can be any oral presentation that is offensive to a patient, visitor or others.

18. Record review of Patient #2's Behavioral Health Assessment, dated 09/10/14, showed the patient was admitted to an adult psychiatric unit on 7 West, on that date with suicidal ideations (thoughts of self-harm) and alcoholism.

19. During an interview on 09/16/14 at 11:05 AM, current Patient #2 stated that:
- The facility failed to consistently follow their policies.
- Patients were treated like "animals." She was left in the Emergency Department (ED) on 09/10/14, on the floor, with vomitus all over her for an extended period of time (this can be a form of neglect).
- On the evening of 09/16/14, staff failed to supervise a male patient allowing him to wander up and down the halls of the female patient corridor. All female patients were fearful and did not get any sleep that night (this can be a form of neglect).

During an interview on 09/22/14 at 10:36 AM, current Patient #2's spouse stated that on 09/10/14 staff left Patient #2 in the ED, on the floor, for over an hour with vomitus all over her. He had to seek, and insist on assistance to get her in a gown and off the floor (this is a form of neglect).

20. During an interview on 09/18/14 at 9:08 AM, current Patient
#11 stated that Staff QQ, RN, threatened to send him outside without a coat, or to the ITU side if he did not behave (this could be considered Class III verbal abuse).

21. Record review of discharged Patient #9's initial psychiatric assessment dated 09/09/14, showed the patient was admitted to the ITU on 09/08/14 with SI. Patient #9 was discharged on 09/17/14 and assessed as alert and oriented at that time.

22. During an interview on 09/17/14 at 12:40 PM prior to the patient leaving the facility, discharged Patient #9 stated that:
- During her hospitalization, she had witnessed three patients being "taken down" by about six staff members each time. Each time, staff were rough and sat on the patient (not considered to be appropriate technique).
- Her smoking privileges were revoked when she became loud with her voice (a type of punishment).
- Staff threatened patients with a "B52" injection (unknown what was in it and used to calm/control the patients if they did not comply with staff direction.)






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