HospitalInspections.org

The Condition of Participation for Patient Rights is not met based on patient interviews, patient verbal and written grievances, staff interviews, a review of hospital policies, procedures and hospital records. It was determined the facility failed ensure patient's right to be free from abuse and to be treated with dignity and respect. The hospital failed to immediately intervene, investigate, and protect all patients when allegations of potential physical abuse, repeated patient complaints of verbal abuse and a report of patient allegation of being sexually assaulted were known by staff. The hospital failed to have a system to protect, report, and investigate allegations of verbal, physical, and sexual activity which was effective and consistently implemented.

This failure by the hospital places all current and future patients at the risk of immediate jeopardy for serious physical and/or psychological harm.
Please refer to A-0118 and A-0145 for additional information.

The findings include:

1. Record review revealed Patient #4 was admitted the evening of 8/10/11, with a diagnosis including Bipolar Disorder. The patient is alert and oriented.

On 8/31/11 a record review revealed a nursing note, dated 8/13/11 at 0300 (3:00 a.m.) which documented, "pt. @ nurses station, had an incident with roommate, pt. very upset, wants room change." The next note, on 8/13/11 is timed at 0600 (6:00 a.m.) and is written by the Registered Nurse. The note includes "pt. still anxious about incident w/roommate during night. P- Arrange for room change ASAP.", "Pt. medicated w/ Haldol 5 mg. p.o. (by mouth) for anxiety." The patient's record shows at 1210 (12:10 p.m.) "Pt. moved to room 203 as per his request."

The record contains a singular progress note signed by a LCSW (case manager), on 8/13/11, at 0900 (9:00 a.m.). The note shows "patient upset regarding being propositioned by his roommate last night. Discussed incident & response and per patient request, requested room change." Review of nurses noted for 8/13/11, shows the note after 1210 is timed for 2200 (10:20 p.m.) and does not mention the roommate involved in the incident.

Interview with the patient on 9/1/11 at 12:05 p.m., revealed he was awoken from sleep by someone fondling his genitalia. The patient said it was very upsetting. He told the nurse on duty what the roommate did and he asked to be moved to another room.

Review of the facility incident log shows that no report was completed. A request was made for the facility to provide any abuse investigation they had completed and they produced one investigation for an incident of 7/12/11.

The patient had reported the fondling of his genitalia to the nursing staff on duty that night. The nurse documented "incident with roommate" and did not document the nature of the incident. The patient's record shows a case manager discussed the incident with the patient on 8/13/11. The nurse and the case manager failed to follow the hospital policy for reporting allegations of abuse and for violations of patient rights /sexual contact between patients. Nursing documentation shows the patient asked for a room change at 3:30 a.m. The patient had to return to the same room to sleep because the documented room change did not occur until 1210 (12:10 p.m.), over eight hours after his request. Nursing staff failed to protect Patient #4 from the potential of further sexual assault that evening. The sexual assault was not reported to the local county sheriff department or to the State of Florida Adult Protective Services, until 9/1/11, after surveyor intervention. After notification to the local county sheriff department, Patient #4 chose to press charges.

Review of the hospital's Policy and Procedure CL-1:026 Violation of Patient Rights/Abuse of Patient, Procedure #1 states "In the event a patient's rights and an abuse of a patient has taken place, the staff member will immediately notify their supervisor at the time if either witnessing abuse or having knowledge that it has occurred." Procedure #2 is "The staff member will immediately complete an incident report and DCF (Department of Children and Families) will be notified by the Supervisor. Procedure #5 is "The staff member shall immediately be put on administrative leave and asked not to report back to work until all investigation is completed." Procedure number #6 of the Policy and Procedure CL-1:026 addresses "Sexual contact between patients."

The procedure is as follows:

a. The Risk Manger and Administrator/designee are immediately notified by the Board of Director of sexual contact between patients and provide as much information as possible regarding the circumstance.
b. The Risk Manager will appoint a staff member to counsel the patients who are kept separate until the interview is completed. The Risk Manager will come to the facility to investigate all allegations and witnesses of sexual abuse between patients within four (4) hours of the report. In the event the Risk Manager is unavailable, a designee may be appointed. The site of the incident is to be secured to assure evidence is not disturbed.
c. In cases in which the patients were both willing participants and they do not want to purse legal action, a signed and witnessed statement to this effect must be written. The statement should be in their own words (preferably their own handwriting) and should include the patient number of the other party involved, the date and time the incident occurred, that the patient was a willing participant and not forced, and the signature of the patient. The statement shall be dated, times and signed by the patient, and witnessed and forwarded with an incident report to the Risk Management Department.
d. The patient's involved will have updated treatment plans to reflect patient goals and staff interventions.
e. If it is determined that there was any nonconsensual activity involved, DCF will be notified. DCF investigators will advise whether or not the incident needs to be reported to law enforcement.

The failure by nursing staff and the case manager to follow the hospital policy and procedure to report the allegation placed all patients, who had the potential to interact with the alleged perpetrator, and all subsequent patients admitted to the hospital at risk for harm.

2. A review of the Patient Grievance Statement for the facility reveals the following grievance signed and dated by Patient #7 on 7/12/11, "MHT Staff #2 grabbed my arm very hard, trying to say I was touching someone inappropriately-which I WAS NOT!"

The facility form documented "Staff Response for facility Grievance: Spoke to Patient notified DON (Director of Nursing) speak to MHT Staff #2, who denies allegation DCF (Department of Children and Family) was notified." This note was dated 7/15/11 and signed by the Risk Manager Designee.

Patient #7 submitted a second grievance dated 7/12/11. The patient was following up on the first grievance. The patient stated again "Staff #2 grabbed my arm so hard he left a mark." This grievance was noted and signed by the Risk Manager Designee (RMD) on 7/12/11. No further action/resolution was noted.

A review of the facility's Incident Summary Report form, dated 7/12/11 reveals the following is documented by the Risk Manager Designee;
a. Date of Incident: 07/12/11; Time of Occurrence: 0630 a.m.;
b. Location of Incident: (the location was not noted)
c. Interview with Patient #7 on 7/12/11, at 1600 (4:00 p.m.), as documented on the form: On 7/12/11 Patient #7 made an allegation that the Mental Health Technician (MHT) grabbed her wrist and instructed the patient that touching other patients would be deemed as inappropriate touching.

This allegation followed an incident report regarding a male patient touching a female patient inappropriately and MHT Staff #2 saw the incident and wrote an incident report which is on file.

Patient #7 stated the MHT Staff #2 grabbed her left right hand and left marks. She showed me her arm on 7/12/11 at 1600 (4:00 p.m.) and again on 7/13/11 at 12:00 p.m. and I could see very faint marks on her wrist.

d. Interview with MHT Staff #2 at 7/13/11 at 1400 (2:00 p.m.):
MHT stated Patient #7 and a male patient were touching appropriately; He (meaning MHT Staff #2) stated the female patient became agitated and MHT pointed to his left index finger on her right forearm to indicate and explain that this was inappropriate touching.

e. Action Taken Place
MHT Staff #2 has been assigned to work in maintenance until the patient has been discharged.

f. Summary
MHT has had disciplinary actions in the past (5/17/11 and 12/29/10).
In regards to the complaint, facts from both parties do not correlate. Patient states MHT grabbed Patient #7's left wrist, whereas MHT states he pointed his index finger to her right forearm."

The Risk Manager Designee was questioned on 08/31/11, at 1:30 p.m., in regards to this incident. When asked if there was any more documentation to include the investigation, the RMD validated that this was all the information she had. When asked again about the investigation, she replied this is all I have.

Review of Patient #7's closed clinical record revealed the patient was admitted to the facility on 07/06/11, voluntarily, with a diagnosis, but not limited to Depression and Opioid Dependency.

Review of the "Supplemental Patient Care Notes" documented by Staff member #7 dated 7/12/2011, reveals the following; "Quiet night except for allegedly reporting MHT Staff #2 involved with touching his private area after he reported this patient being involved physically with another male peer who was inappropriately touching his private area. Medical doctor (MD) made aware. Director of Nursing (DON) and administrator (illegible)."

Review of the clinical record to include Physician Progress notes and Nurses progress notes, did not demonstrate any other documentation that pertain to the incident reported to the RMD.

3. When a request for the hospital grievance log was made, on 8/30/11, the Risk Manager explained that part of the log was missing due to staff turnover. Written patient complaints were provided for review. Review revealed that grievances of staff yelling at patients or being disrespectful had not resulted in any action.

Review of Patient #2's Facility Grievance Statement signed on 7/30/11 reads as follows: Section I "Staff member #3 yelled at me for smoking on the edge of the patio. I told her I was told to smoke (here) cause I couldn't take the wheelchair in the dirt/sand. She (meaning Staff #3) continued to be very mean and hateful and yelling. Another worker was with her but I didn't get her name."

Staff Response dated 8/01/11: Section 2. "Instructed technician that all patients who have a walking cane or wheelchair are allowed on concrete until completion of concrete walkway." The Staff response does not identify the concerns the patient had in regards to yelling or being hateful, but with the condition of the walking surface ... Review of Patient #2 clinical record does not demonstrate that actions or interventions were conducted as it pertains to the grievance.

The Risk Manager Designee (RMD) was questioned on the grievance and interventions taken, and confirmed this is the information she had on the outcome of the issue.

4. An unidentified direct care staff member was interviewed on 08/30/11 at 8:30 a.m., about abuse and neglect. When asked if the staff member received any education/in-services on abuse and neglect, and how to report abuse and neglect the staff member replied, yes during my initial orientation after being hired. When the staff member was asked if there have been any other inservices on this subject, she replied no, the facility does not even have a staff member assigned to in-service education.

5. It was noted that multiple patient complaints were made about one particular nurse (Staff #1) as follows:

On 4/26/11 a random patient wrote that sampled Staff #1 "came outside hollering at all of us for no reason. She is totally out of control and needs to be talked to. She came out hollering for no reason we didn't even have to come in." The facility responded by notifying the Director of Nurses (DON) on 4/27/11 and documented "Issue is being addressed. Spoke with both clients on 4/27/11 with DON." No further action/resolution is noted.

On 5/18/11 a random patient wrote in their grievance, "(Staff #1) is extremely mean and disrespectful." The patient then went on to make other negative comments regarding the nurse's treatment of patients. The hospital response on 5/26/11 is documented as, "We have spoken to her in a meeting along with Human Recourses and came to agreements."

On 7/4/11 Patient #7 submitted a grievance which documents, "The night nurse (Staff #1) treats us as if we are soldiers instead of people trying to get help. I don ' t feel that I should be talked down to, or made to feel like a loser, she made - so angry that I punched the wall and I believe I broke two knuckles." Hospital response was documented as, "Nurse and DON has been informed."

On 7/7/11 a male random patient filed a grievance which documents, "I requested for (Staff #1) to get a carton of cigarettes which was about 8 ft. from where she was seated. She replied she was busy, OK fine, she was busy. It was then my responsible to get a Tech from the cafeteria who was also busy but walked all the way to the nurse's station to help me get my cigarettes." The hospital response documents "Apology has been requested and apology has been granted."

On 7/27/11, a random male patient documented on a grievance form, "Tuesday night July 26 2011 approx. 10:25 p.m. I was at the med window, the med nurse was getting my meds ready and gave me the OK to put my inhaler back in the Med Bin. So I did and - (Staff #1) went off on me, "don't you ever put your hand over this counter again." " I said can you please talk to me a little nicer?" No further action/resolution is noted.

On 7/29/11 a random patient Grievance Statement shows "All techs yelling at the patients and Nurse (Staff #1) was yelling at patients Nurse (Staff#1) grabbed patient, tech yelled at me, I yelled back." There is no Staff Response documented on the form.

A Patient Grievance Form completed on 7/30/11shows "Staff member (unknown) yelled at me for smoking on the edge of the patio. I told her I was told to smoke there ..." The facility response address patients with wheelchairs and walkers being allowed on the concrete however the issue of staff yelling at a patient is not addressed.

A grievance form dated 7/31/11 documents a patient filed a complaint because Staff #1 would not contact the doctor at the patient's request which was made at 8 p.m. The patient wanted the nurse to tell the doctor that the sleeping pill was not working. The patient documented, "I am desperate for sleep." No further action/resolution is noted.

On 7/29/11 an incident was documented to occur where Patient #8 was not feeling well and wanted to go to bed. The patient had pseudo-seizures and was shaking. She was in a wheel chair. Staff #1 would not allow the patient to go to her bedroom, stating it was not safe. The staff documented she did not have a Mental Health Technician to stay with her so the patient wouldn't fall. A patient tried to push the wheelchair to the bedroom. Sampled Nurse #4 was on duty that evening. She completed a statement describing Staff #1's refusal to let Patient #8 go to bed. The nurse documented "(Staff #1) refused to allow pt. to go to her room. Literally dragging her back in a wheelchair and put in front of nurses station for everyone to see stating "You're faking it! Stop crying! You're just trying to get meds and attention! Well, you can just sit her and get all the attention you want! This was yelled at the patient."

The nurse also documented that the other patients tried to talk Staff #1 into taking Patient #8 to her room but Staff #1 refused and started yelling at the remainder of the patients. " She also wrote that the other patients tried to defend Patient #8 but that Staff #1 continued to antagonize the patients. The patients had called the police who came to the hospital. This incident resulted in six patient complaints regarding Staff #1's treatment of Patient #8. Three of the six have a response that the DON was notified. No further action/resolution is noted.

Staff #1 documented in the nursing progress notes that it would not be safe for Patient #8 to go to her room because she didn't have a Mental Health Technician (MHT) to sit with her. A review of the staffing schedule for the evening on 7/29/11 shows eight MHT's on duty in the hospital.

6. During an interview with Staff #7 on 8/31/11 at approximately 6:10 p.m., the staff verified there was a nurse (Staff #1), not here anymore, that was abusive towards patients. The nurse stated, she got angry, didn't call them names, but would say, 'you'd better be quiet! It was her mannerisms." This nurse said she reported this to the former DON and she thought several people had mentioned how the nurse was. A written statement was given to the former DON at the DON's request. This staff stated that Staff #1 was heard talking sternly to patients and getting them upset.

7. Interview with Staff #8, on 8/31/11 at 6:45 p.m., revealed the staff observed the incident of 7/29/11. The staff stated that Patient #8 wanted to go to bed. The patients got together and were screaming. When asked if she reported the incident, she did not. She said that she was passing meds. When asked what she would have done in response to the incident she said if she was the charge nurse she would have put her to bed with a MHT to watch her.

8. On 8/30/11 at 1:15 p.m., during an interview with the former Director of Nurses, she said that she had done multiple disciplinary actions with this nurse. She stated the nurse had mood swings and would yell at nurses and patients and was intrusive. She said the third to the last complaint was that the nurse grabbed some one inappropriately and accused different patients of different things. She kept trying to work with her. When asked if this situation was therapeutic for the patients she agreed that it was not. She also said, "A lot of patients got very angry, she would go back to them, they would escalate, throw things."

9. An interview with the Acting Director of Nurses on 8/31/11, at approximately 12:35 p.m., shows she became aware of the nurse's behavior toward patients when she read Staff #4's report of the 7/29/11 incident. She also said that another staff member came to her after the nursing staff meeting on 8/2/11 to report the behavior of Staff #1. When she received a report of physical mishandling she went to the administrator and personnel director to start the process to terminate the staff. The nurse was terminated on 8/12/11 however, the nurse continued to work nine shifts from the 7/29/11 incident to 8/11/11. In addition, this nurse continued working in the same area for approximately 4 months after the first patient complaints were presented.

During that time, the former Director of Nurses was aware of patient complaints of verbally abusive behavior towards the patients. Although the former DON stated she tried to work with her, the personnel record does not show that interventions were implemented to remove the nurse from patient contact and monitor this nurse's patient interactions from 4/11 to 8/11. Failure to intervene and remove the nurse from patient contact put all patients at risk for emotional harm.




18563

Based on patient interviews and verbal complaints, staff interviews, a review of hospital policies, procedures and hospital records and a review of written patient complaints, it was determined the facility failed to ensure the prompt resolution of patient grievances.

The findings include:

On 8/30/11 a request was made for the hospital Grievance Log. A partial log was provided and the Risk Manager stated that the log was lost between the previous staff leaving and the Risk Manager Designee arriving.

The hospital provided copies of patient complaints for review.

During an interview with Patient #4 on 8/30/11 at approximately 1:30 p.m., the patient was asked if he had given the hospital a written complaint regarding the concerns he was stating. He replied "the grievance forms just disappear."



Review of the hospital Policy and Procedure R.M.- 016 for Patient Complaints/ Patient Grievances shows:

Once the patient has written and signed the grievance, the form is to be returned to the patient advocate and within three business days the advocate will discuss the concern with the patient and prepare a written response. The response is recorded in Section 2 of the Complaint/Grievance Report Form. The grievance form provided by the hospital show that approximately 50% have no facility response documented.

Based on patient interviews and verbal complaints, staff interviews, review of hospital policies, procedures and hospital records and a review of written patient complaints, it was determined the facility failed to ensure the right of patients to be free from abuse; failed to intervene and protect patients when allegations of mistreatment and sexual contact between patients were reported; failed to follow their policy and procedures for violations of patient's right's, patient abuse and sexual allegations and failed to respond to patient grievances. The hospital failed to immediately intervene, investigate and protect all patients when allegations of potential physical abuse, repeated patient complaints of verbal abuse and a report of patient's allegation of being sexually assaulted were known by staff.

The findings include:

1. Record review revealed Patient #4 was admitted the evening of 8/10/11, with a diagnosis including Bipolar Disorder. The patient is alert and oriented.

On 8/31/11 a record review revealed a nursing note, dated 8/13/11 at 0300 (3:00 a.m.) which documented, "pt. @ nurses station, had an incident with roommate, pt. very upset, wants room change." The next note, on 8/13/11 is timed at 0600 (6:00 a.m.) and is written by the Registered Nurse. The note includes "pt. still anxious about incident w/roommate during nights. P- Arrange for room change ASAP.", "Pt. medicated w/ Haldol 5 mg. p.o. (by mouth) for anxiety." The patient's record shows at 1210 (12:10 p.m.) "Pt. moved to room 203 as per his request."

The record contains a singular progress note signed by a LCSW (case manager), on 8/13/11, at 0900 (9:00 a.m.). The note shows "patient upset regarding being propositioned by his roommate last night. Discussed incident & response and per patient request, requested room change, propositioned by roommate." Review of nurses noted for 8/13/11, shows the note after 1210 is timed for 2200 (10:20 p.m.) and does not mention the roommate.

Interview with the patient on 9/1/11 at 12:05 p.m., revealed he was awoken from sleep by someone fondling his genitalia. The patient said it was very upsetting. He told the nurse on duty what the roommate did and he asked to be moved to another room.

Review of the facility incident log shows that no report was completed. A request was made for the facility to provide any abuse investigation they had completed and they produced one investigation for an incident of 7/12/11.

The patient had reported the fondling of his genitalia to the nursing staff on duty that night. The nurse documented "incident with roommate" and did not document the nature of the incident. The patient's record shows a case manager discussed the incident with the patient on 8/13/11. The nurse and the case manager failed to follow the hospital policy for reporting allegations of abuse and for violations of patient rights /sexual contact between patients. Nursing documentation shows the patient asked for a room change at 3:30 a.m. The patient had to return to the same room to sleep because the documented room change did not occur until 1210 (12:10 p.m.), over eight hours after his request. Nursing staff failed to protect Patient #8 from the potential of further sexual assault that evening. The sexual assault was not reported to the local county sheriff department or to the State of Florida Adult Protective Services, until 9/1/11, after surveyor intervention. After notification to the local county sheriff department, Patient #8 chose to press charges.

Review of the hospital's Policy and Procedure CL-1:054 Patient Abuse and Neglect Reporting shows it is the policy of the hospital "to respect the individual dignity of each patient and ensure patients that they will be protected insofar as is possible from abuse or neglect of any kind. It is required by law I the State of Florida that every patient be guaranteed freedom from abuse and/or neglect. In addition, it is required that all health care facilities provide for the reporting of patient abuse - by patients, staff or others."

Review of the hospital's Policy and Procedure CL-1:026 Violation of Patient Rights/Abuse of Patient, Procedure #1 states "In the event a patients rights and an abuse of a patient has taken place, the staff member will immediately to notify their supervisor at the time if either witnessing abuse or having knowledge that it has occurred." Procedure #2 is "The staff member will immediately complete an incident report and DCF (Department of Children and Families) will be notified by the Supervisor. Procedure #5 is "The staff member shall immediately be put on administrative leave and asked not to report back to work until all investigation is completed."

Procedure number #6 of the Policy and Procedure CL-1:026 addresses "Sexual contact between patients."
The procedure is as follows:
a. The Risk Manger and Administrator/designee are immediately notified by the Board of Director of sexual contact between patients and provide as much information as possible regarding the circumstance.

b. The Risk Manager will appoint a staff member to counsel the patients who are kept separate until the interview is completed. The Risk Manager will come to the facility to investigate all allegations and witnesses of sexual abuse between patients within four (4) hours of the report. In the event that the Risk Manager is unavailable a designee may be appointed. The site of the incident is to be secured to assure evidence is not disturbed.

c. In cases in which the patients were both willing participants and they do not want to purse legal action, a signed and witnessed statement to this effect must be written. The statement should be in their own words (preferably their own handwriting) and should include the patient number of the other party involved, the date and time the incident occurred, that the patient was a willing participant and not forced, and the signature of the patient. The statement shall be dated, times and signed by the patient and witnessed and forwarded with an incident report to the Risk Management Department.

d. The patient's involved will have updated treatment plans to reflect patient goals and staff interventions.

e. If it is determined that there was any nonconsensual activity involved, DCF will be notified. DCF investigators will advise whether or not the incident needs to be reported to law enforcement.

The failure by nursing staff and the case manager to follow the hospital policy and procedure to report the allegation placed all patients, who had the potential to interact with the alleged perpetrator, and all subsequent patients admitted to the hospital at risk for harm.

2. A review of the Patient Grievance Statement for the facility reveals the following grievance signed and dated by Patient #7 on 7/12/11, "MHT Staff #2 grabbed my arm very hard, trying to say I was touching someone inappropriately-which I WAS NOT!"

The facility form documented "Staff Response for facility Grievance: Spoke to Patient notified DON (Director of Nursing) speak to MHT Staff #2 who denies allegation DCF (Department of Children and Family) was notified." This note was dated 7/15/11 and signed by the Risk Manager Designee.

A second grievance submitted by Patient #7 dated 7/12/11 reads, "Staff #2 follow 1st grievance he meaning Staff #2 grabbed my arm so hard he left a mark." This grievance was noted and signed by the Risk Manager Designee (RMD) on 7/12/11. No Further action/resolution was noted.

A review of the facility's Incident Summary Report form, dated 7/12/11 reveals the following;
a. Date of Incident: 07/12/2011; Time of Occurrence: 0630a.m.;
1) Location of Incident: (the location was not noted)
b. Interview with Patient #7 on 7/12/11 at 1600 (4:00 p.m.) ,as documented on the form
On 7/12/11 Patient #7 made an allegation that the Mental Health Tech (MHT) grabbed her (meaning Patient #7) wrist and instructed the patient that touching other patients would be deemed as inappropriate touching.
This allegation followed an incident report regarding a male patient touching female patient inappropriately and MHT Staff #2 saw the incident and wrote an incident report which is on file.
Patient #7 stated that the MHT Staff#2 grabbed her left right hand leaving marks. She showed me her arm on 7/12/11 at 1600 (4:00 p.m.) and again on 7/13/11 at 12:00 p.m. and I could see very faint marks on her wrist (meaning Patient #7).
c. Interview with MHT Staff #2 at 7/13/11 at 1400 (2:00p.m.):
MHT stated that Patient #7 and a male patient were touching in appropriately; He (meaning MHT Staff #2) stated the female patient became agitated and MHT pointed to his left index finger on her right forearm to indicate and explain that this was inappropriate touching.
d. Action Taken Place
MHT Staff #2 has been assigned to work in maintenance until the patient has been discharged.
e. Summary
MHT has had disciplinary actions in the past 5/17/11 and 12/29/10.
In regards to the complaint, facts from both parties do not correlate, patient states MHT grabbed patient #7 left wrist, whereas MHT states he pointed his index finger to her right forearm. "

The Risk Manager Designee was questioned on 08/31/2011 at 1:30 p.m. in regards to this incident. The RMD when asked if there was any more documentation to include the investigation, the RMD validated this is all the information she had. When asked again about the investigation, she replied this is all I have.

Review of Patient #7 closed clinical record revealed the patient was admitted to the facility on 07/06/11 voluntarily, with a diagnosis, but not limited to Depression and Opioid Dependency.

Further review of the "Supplemental Patient Care Notes" documented by Staff member #7 dated 7/12/2011 reveals the following; "Quiet night except for allegedly reporting MHT Staff #2 involved with touching his private area after he report this patient being involved physically with another mail peer who was inappropriately touching his private area. Medical doctor (MD) made aware. Director of Nursing (DON) and administrator (illegible)."

Further review of the clinical record to include Physician Progress notes and Nurses progress notes, did not demonstrate any other documentation that pertain to the incident reported to the RMD. No documentation could be found related to the marks on the writst of Patient #7.

3. When a request for the hospital grievance log was made, on 8/30/11, the Risk Manager explained that part of the log was missing due to staff turnover. Written patient complaints were provided for review.

Review of Patient#2 Facility Grievance Statement signed on 7/30/11 reads as follows; "Staff member #3 yelled at me for smoking on the edge of the patio. I told her I was told to smoke cause I couldn't take the wheelchair in the dirt/sand. She(meaning Staff #3) continued to be very mean and hateful and yelling. Another worker was with her but I didn't get her name."

Staff Response dated 8/01/11: "Instructed technician that all patients who have a walking cane or wheelchair are allowed on concrete until completion of concrete walkway."

The Staff response does not identify the concerns the patient had in regards to yelling or being hateful. Furthermore review of Patient #2 clinical record does not demonstrate that any action or interventions were conducted as it pertains to the grievance.

The Risk Manager Designee (RMD) was questioned on the grievance and interventions taken, and confirmed this is the only information she had on the outcome of the issue.

4. An unidentified direct care staff member was interviewed on 08/30/11 at 8:30 a.m. in regards to abuse and neglect. When asked if the staff member received any education/in services on abuse and neglect, and how to report abuse and neglect the staff member replied, yes during my initial orientation after being hires. When the staff member was asked if there have been any other in services on this subject, she replied no, the facility does not even have a staff member assigned to in service education.

5. It was noted that multiple patient complaints were made about one particular nurse (Staff #1)as follows:

On 4/26/11 a patient wrote that sampled Staff #1 "came outside hollering at all of us for no reason. She is totally out of control and needs to be talked to. She came out hollering for no reason we didn't even have to come in." The facility responded by notifying the Director of Nurses (DON) on 4/27/11 and it's documented "Issue is being addressed. Spoke with both clients on 4/27/11 with DON. No further action/resolution is noted.

On 5/18/11 a patient wrote in their grievance, "(Staff #1) is extremely mean and disrespectful." The patient then went on to make other negative comments regarding the nurse's treatment of patients. The hospital response on 5/26/11 is documented as, "We have spoken to her in a meeting along with Human Recourses and came to agreements."

On 7/4/11 Patient #7 submitted a grievance which documents, "The night nurse (Staff #1) treats us as if we are soldiers instead of people trying to get help. I don ' t feel that I should be talked down to, or made to feel like a loser, she made - so angry that I punched the wall and I believe I broke two knuckles." Hospital response was documented as, "Nurse and DON has been informed."

On 7/7/11 a male patient filed a grievance which documents, "I requested for (Staff #1) to get a carton of cigarettes which was about 8 ft. from where she was seated. She replied she was busy, OK fine, she was busy. It was then my responsible to get a Tech from the cafeteria who was also busy but walked all the way to the nurse's station to help me get my cigarettes." The hospital response documents "Apology has been requested and apology has been granted."

On 7/27/11 patient documented on a grievance form, "Tuesday night July 26 2011 approx. 10:25 p.m. I was at the med window, the med nurse was getting my meds ready and gave me the OK to put my inhaler back in the Med Bin. So I did and - (Staff #1) went off on me, "don't you ever put your hand over this counter again." "I said can you please talk to me a little nicer?" No further action/resolution is noted.

A Patient Grievance Form completed on 7/30/11shows "Staff member (unknown) yelled at me for smoking on the edge of the patio. I told her I was told to smoke there ..." The facility response address patients with wheelchairs and walkers being allowed on the concrete however the issue of staff yelling at a patient is not addressed.

A grievance form dated 7/31/11 documents a patient filed a complaint because Staff #1 would not contact the doctor at the patient's request which was made at 8 p.m. The patient wanted the nurse to tell the doctor that the sleeping pill was not working. The patient documented, "I am desperate for sleep." No further action/resolution is noted.

On 7/29/11 an incident was documented to occur where Patient #8 was not feeling well and wanted to go to bed. The patient had pseudo-seizures and was shaking. She was in a wheel chair. Staff #1 would not allow the patient to go to her bedroom, stating it was not safe. The staff documented she did not have a Mental Health Technician to stay with her so the patient wouldn't fall. A patient tried to push the wheelchair to the bedroom. Another nurse on duty completed a statement describing Staff #1's refusal to let Patient #8 go to bed. The nurse documented" (Staff #1) refused to allow pt. to go to her room. Literally dragging her back in a wheelchair and put in front of nurses station for everyone to see stating "You're faking it! Stop crying! You're just trying to get meds and attention! Well, you can just sit her and get all the attention you want! This was yelled at the patient." The nurse documented that the other patients tried to talk Staff #1 into taking Patient #8 to her room but Staff #1 refused and started yelling at the remainder of the patients." She also wrote that the other patients tried to defend Patient #8 but that Staff #1 continued to antagonize the patients. The patients had called the police who came to the hospital. This incident resulted in six patient complaints regarding Staff #1's treatment of Patient #8. Three of the six have a response that the DON was notified. No further action/resolution is noted.

Staff #1 documented in the nursing progress notes that it would not be safe for Patient #8 to go to her room because she didn't have a Mental Health Technician (MHT) to sit with her. A review of the staffing schedule for the evening shift that eight MHT's on duty the evening of 7/29/11.

6. During an interview with a hospital nurse on 8/31/11 she verified there was a nurse at the facility that was abusive towards patients. The nurse stated, "she got angry, didn't call them names, but would say, 'you'd better be quiet!, it was her mannerisms." This nurse said she reported this to the former DON and she though several people had mentioned how the nurse was. Another staff interview on 8/31/11 revealed that a written statement was given to the former DON. at the DON's request. This staff stated that Staff #1 was heard talking sternly to patients and get them upset. Interview with Staff #8, on 8/31/11 at 6:45 p.m. revealed that the staff observed the incident of 7/29/11. The staff stated that Patient #8 wanted to go to bed. The patients got together and were screaming. When asked if she reported the incident, she did not. She said that she was passing meds. When asked what she would have done in response to the incident she said if she was the charge nurse she would have put her to bed with a MHT to watch her.

7. On 8/30/11 at 1:15 p.m., during an interview with the former Director of Nurses, she said that she had done multiple disciplinary actions with this nurse. She stated the nurse had mood swings and would yell at nurses and patients and was intrusive. She said the third to the last complaint was that the nurse grabbed some one inappropriately and accused different patients of different things. She kept trying to work with her. When asked if this situation was therapeutic for the patients she agreed that it was not. She also said, "a lot of patients got very angry, she would go back to them, they would escalate, throw things." Interview with the Acting Director of Nurses shows that she became aware of the nurse's behavior toward patients when she read the nurses report of the 7/29/11 incident. The nurse was terminated on 8/12/11 however, the nurse continued to work nine shifts from the 7/29/1 incident to 8/11/11. In addition, this nurse continued working in the same area for approximately 4 months after the first patient complaints were presented . On 7/29/11 a patient Grievance Statement shows All techs yelling at the patients and Nurse (Staff #1) was yelling at patients Nurse (Staff#1) grabbed patient, tech yelled at me, I yelled back. "

During that time, the former Director of Nurses was aware of patient complaints of verbally abusive behavior towards the patients. Although the DON stated she tried to work with her, the personnel record does not show that interventions were implemented to remove the nurse from patient contact and monitor this nurse ' s patient interactions from 4/11 to 8/11. Failure to intervene and remove the nurse from patient contact put all patients at risk for emotional harm.

Interview with the acting DON on 8/31/11 at 12:05 reveals that when she became aware of the complaints regarding Staff #1she reviewed the complaints an the personnel record. She said that a staff came to her after the nursing staff meeting on 8/2/11 to report the behavior of Staff #1. She received a report of physical mishandling and went to the administrator and personnel director to start the process to terminate the staff.

This Condition of Participation is not met based on patient interview, interview with former Director of Nursing, review of patient grievances, staff interview and record review it is determined the hospital nursing staff failed to provide care and services to all patients based on patient's right to be treated with dignity, respect and to be free from abuse.

The Director of Nursing failed to follow the facility policy related to staff abuse of patients.

The findings include:



1. On 8/31/11 a record review revealed a nursing note, dated 8/13/11 at 0300 (3:00 a.m.) which documented, "pt. @ nurses station, had an incident with roommate, pt. very upset, wants room change." The next note on 8/13/11 is timed at 0600 (6:00 a.m.) and is written by the Registered Nurse. The note includes "pt. still anxious about incident w/roommate during nights. P- Arrange for room change ASAP.," "Pt. medicated w/ Haldol 5 mg. p.o. (by mouth) for anxiety." The patient's record shows that at 1210 (12:10 p.m.) "Pt. moved to room 203 as per his request."

The record contains a singular progress note signed by a LCSW (case manager), on 8/13/11, at 0900 (9:00 a.m.). The note shows "patient upset regarding being propositioned by his roommate last night. Discussed incident & response and per patient request, requested room change......"

Interview with the patient on 9/1/11 at 12:05 p.m. revealed that he was awoken from sleep by someone fondling his genitalia. The patient said it was very upsetting. He told the nurse on duty what the roommate did and he asked to be moved to another room.

Review of nurses noted for 8/13/11 shows a note timed for 2200 (10:20 p.m.) and does not mention the roommate.

Review of the facility incident log shows that no report was completed. A request was made for the facility to provide any abuse investigation they had completed. The Risk Manager provided one investigation of abuse for an incident that occurred on 7/12/11. The Risk Manager was asked if this was the only investigation completed and confirmed there was only one. There was no investigation for the incident on 8/13/11.

The patient had reported the fondling of his genitalia to the nursing staff on duty that night. The nurse documented "incident with roommate" and did not document the nature of the incident. The nurse failed to follow the hospital policy for reporting allegations of abuse and for violations of patient rights /sexual contact between patients. Administrative staff and the Risk Manger/Designee had not been informed of the incident. Nursing documentation shows the patient asked for a room change at 3:30 a.m. The patient had to return to the same room to sleep because the documented room change did not occur until 1210 (12:10 p.m.), over eight hours after his request. Nursing staff failed to protect Patient #8 from the potential of further sexual assault that evening.

Nursing staff failed to exercise their duty to protect patients from abuse and report allegations of abuse.


2. Patient Grievance Statements reviewed show complaints against Staff#1 were made from 4/26/11 through 7/29/11. The complaints concerned verbal mistreatment towards patients, refusal to call the physician at the patient's request, and mistreatment of Patient #8.

On 8/31/11 at 1:10 p.m. when the Risk Manager Designee was asked about the number of Grievances involving Staff #1 she stated they saw a trend of complaints. Staff #1 had been counseled. She stated that one night Staff # 4 witnessed Staff #1 almost inciting a riot, the patients would call 911. She stated the other nurses were afraid to stand up to Staff #1 because she was verbally aggressive. She said when the new hospital Administrator arrived she went to him and Staff #1 was finally terminated in August.

3. Interviews during the survey with Staff #4, #6, #7, #8 and the former Director of Nurses confirmed that Staff #1 was inappropriately interacting with patients. Nursing staff did not report any observed verbal aggression towards patients.

On 8/30/11 at 1:15 p.m., during an interview with the former Director of Nurses, she said she had done multiple disciplinary actions with this nurse (Staff #1). She stated the nurse had mood swings and would yell at nurses and patients and was intrusive. She said the third to the last complaint was of the nurse grabbing some one inappropriately and accused different patients of different things. She kept trying to work with her. When asked if this situation was therapeutic for the patients she agreed that it was not. She also said, "A lot of patients got very angry, she would go back to them, they would escalate, throw things."