HospitalInspections.org

Based on staff interviews, review of facility documents, and a review of video footage, it was determined the facility failed to ensure patients receive care in a safe environment.

Findings include:

1. The facility failed to ensure patient safety is maintained by immediately intervening when a staff member engaged in a physical confrontation with a patient. (Cross refer to Tag A-144)

2. The facility failed to ensure staff were re-educated regarding de-escalation techniques and failed to ensure implementation of the facility's Standards of Behavior Policy, after a staff member and a patient engaged in a physical altercation. (Cross refer to Tag A-144)

Based on review of facility security footage and facility documents, and staff interviews, it was determined the facility failed to ensure that: 1) patient safety is maintained by immediately intervening when a staff member engaged in a physical confrontation with a patient; 2) staff were re-educated regarding de-escalation techniques and implementation of the facility's Standards of Behavior policy after a staff member and patient engaged in a physical altercation.

Findings include:

Reference: Facility policy titled, "Standards of Behavior" (effective 3/2021) states, "The Standards of Behavior policy provides team members with information on the basic direction that [name of facility] expects them to follow. Every team member, regardless of his or her position in the organization, is required to follow these standards. ... Examples of negative behaviors that can adversely impact a positive working environment and may lead to disciplinary action up to and including termination: ... Abusive behavior or inappropriate physical contact of any kind, including both verbal and non-verbal actions, such as the use of profanity, vulgarity, or violent intemperate, intimidating, or threatening gestures, actions or language or behavior. ... ."

1) During the entrance conference on 10/30/23 at 10:30 AM, in the presence of Staff #1 (S1), Assistant Vice President of Nursing, and Staff #2 (S2), Assistant Vice President of Risk, S1 and S2 confirmed that on 10/23/23 at approximately 2:30 AM, Staff #13, a Mental Health Technician (MT), engaged in a physical altercation with Patient #1 (1). Staff #2 stated that after the incident, Staff #13 (S13) was originally sent to another unit to work, but was then sent home at approximately 4:00 AM by the nursing supervisor. A request was made to S 1 and S 2 to review the video footage.

On 10/30/23 at 1:30 PM, the video footage of the incident that took place on 10/23/2023 at approximately 2:30 AM was reviewed in the presence of Staff #5 (S5), the Head of Security, and revealed the following:

At 2:27 - P1 was seated at a table in the common area with Staff #14 (S14), an MT. S14 was the staff member assigned to perform one-to-one (1:1) observation for P1.

At 2:28:18 - S13 enters the dining room and proceeds to the back of the room to obtain, what appears to be, a carton of milk. S14, who was performing the 1:1 observation of the patient, stated the patient was asking for milk and S13 went to get the milk for him/her. He/she walks over to the table where P1 and S14 are sitting and hands P1 the item, then walks away.

At 2:28:48 - S13 returns to the table and approaches P1. P1 and S14 remain seated while S13 stands over P1 with his/her face in close proximity to P1's face. S13 is verbally engaged with P1 while also "posturing" in an aggressive manner towards P1 by raising his/her arms and bobbing his/her head at P1 while speaking. S14 remained seated and did not intervene. P1 remained seated during this encounter. S13 then walks away from the table and out of the camera frame.

At 2:29 - S13 quickly approaches P1 a third time. P1 turns and sees S13 approaching, and stands up. The chair P1 was sitting on falls to the ground as P1 stands up. S13 moved the chair out of the way and stands in P1's face, so that S13 and P1 are standing chest to chest. S13 and P1 were verbally engaged when S13 grabbed P1 around the collar and attempted to throw P1 to the ground. P1 then grabbed S13 and both began physically grabbing each other. S13 then pushed P1 backwards and P1 tripped over furniture and fell to the floor with S13 on top of him/her. At this point, it is difficult to visualize S13 and P1, as the view is blocked by furniture while they are on the floor.

At 2:29:1 - S14 was observed standing over S13 and P1 while they were both on the floor, with S13 still on top of P1.

At 2:29:22 - Staff #15 (S15), MHT, goes over to S13 and P1 and attempts to pull S13 off P1.

At 2:29:33 - A female staff member (unidentified) comes from the back of the room into the camera frame. S13 is now off of P1.

At 2:29:39 - Staff #19 (S19), RN, walks over to where S13 and P1 were. P1 is lying on the floor in the common area with S14 by his/her head and shoulder. S13 is walking away from P1 and staff are helping P1 to his/her feet.

At 2:30:03 - Staff #17 (S17), a MHT, arrived to the unit and walked over to P1 to assist. S13 was still in the common area.

At 2:31 - P1 was calmly sitting at a table in the common area with S14 and S19.

At 2:32:10 - P1 stands and then walks into his/her room (the room is adjacent to the table where P1 was sitting). S19 and S14 follow P1. S14 enters the room directly behind P1. S19 remains outside of the room.

At 2:32:17 - S13 walks past S19, towards P1's room. S13 then stands near the doorway, inside P1's room, in the presence of S17. S19, S17, and S14, did not attempt to prevent S13 from approaching P1's room or from standing near the doorway inside P1's room, despite P1 and S13's physical altercation minutes prior.

At 2:32:18 - P1 walked out of his/her room and into the common area, followed by S13, S14, S19, and S17.

At 2:32:58 - S13 was verbally engaged with P1 in the presence of S13, S14, S17, and S19.

At 2:35:22 - Staff #18 (S18), a Crisis Intervention Specialist, arrived to the unit and walked to the back of the room.

At 2:35:38 - S18 was engaged in conversation with P1. P1 and S18 began walking towards the nursing station.

At 2:35:44 - S13 follows P1 and initiated verbal contact with the patient. P1 stopped walking and turned around to face S13 as he/she continued walking towards P1. Both P1 and S13 were speaking to each other.

At 2:35:50 - P1 took a step towards S13 and S18 put P1 in a physical hold. S18 then began to walk P1 towards the nurse's station and out of the camera frame.

At 2:36:17 - P1, S18, and S14 arrive to the Quiet Area (QA) room. S13 is walking behind P1 and S18. S19 was already in the QA room, as he/she had unlocked the door. S13 enters the QA room with P1, S14, and S18.

At 2:37 - S17 arrives to the QA room.

At 2:38 - S19 leaves the QA room.

At 2:38:30 - Staff #20 (S20), a Security Officer, arrives to the QA room and stands outside of the doorway.

At 2:44 - S13 is inside the QA room leaning against the wall in the presence of S19, S20, and S17. P1 was sitting down, inside the QA room, on the bed.

At 2:44:21 - S13 leaves the QA room and does not return to the area.

On 10/30/23 at 1:30 PM, S5 confirmed all findings from the security video footage.

Upon interview on 10/31/23 at 12:24 PM, Staff #12 (S12), the Vice President of Patient Care Services, stated if a physical altercation occurs between a staff member and a patient then it is the responsibility of the staff members who are present to separate the individuals that are involved in the physical altercation. S12 stated that "any staff member who observes another staff member behaving in an inappropriate manner is able to ask the staff member who is behaving inappropriately to leave the unit and possibly go home." S12 also stated that "if a staff member engages in a physical or verbal altercation with a patient, then they must be kept away from the patient."

On 10/31/23 at 12:30 PM, S2 and S12 confirmed the facility does not have a policy regarding the procedure on removing a staff member from the unit and the facility if they are conducting themselves in an inappropriate manner.

On 10/31/23 at 10:15 AM, an interview was conducted with S20, a Security Officer, who was present during the incident on 10/23/23. S20 stated he/she received a security alert at approximately 4:15 AM on 10/23/23 from the ACU - East Unit. S20 stated that when he/she arrived to the unit, "The situation was pretty much over. Everyone was in the QA room already." S20 stated, "The patient kept yelling the same thing over and over. [He/She] kept saying 'hit me, hit me. I'm reporting you.' I guess the patient was referring to [S13]. [S13] was present and the patient kept talking to [him/her]. We kept assuring [him/her] we would handle it because [he/she] was worried it would be swept under the rug." S20 stated he/she waited in the QA room for 15 to 20 minutes after P1 began to de-escalate. S20 stated that even though P1 was fixated on S13 and was making claims of abuse towards S13, S13 was not removed from the vicinity of P1 or the unit because, "we needed all hands-on deck" in order to de-escalate P1. S20 was asked why he/she did not remove S13 from the unit if P1 was fixated on him/her and saying S13 assaulted him/her. S20 stated, "Patients accuse staff of things every day. We have to follow a chain of command. I'm not going to be the one to remove anyone." S20 stated he/she did not have any further discussion regarding the incident, with anyone. Upon interview, S20 stated he/she did not receive any re-education regarding the facility's Standard of Behavior policy, post incident.

At 11:35 AM, an interview was conducted with Staff #14 (S14), a MHT. S14 confirmed he/she was performing one-to-one (1:1) observation for P1 during the incident that took place on 10/23/23. S14 confirmed he/she did not intervene the second and third time S13 approached P1 and had a verbal encounter with him/her, while P1 was seated at a table in the common room. S14 stated that P1 repeatedly accused S13 of assaulting him/her. S14 also confirmed that S13 remained on the unit and in the immediate vicinity of P1 after the incident.
S14 was asked why he/she did not intervene when S13's behavior toward P1 began to escalate. S14 stated, "I did send him to the nurse's station because I needed to de-escalate him." S14 denied receiving education regarding the facility's Standards of Behavior policy, post incident.

At 12:33 PM, an interview was conducted with Staff #18 (S18), Crisis Intervention Supervisor (CIS). S18 stated that on 10/23/23 at approximately 2:30 AM, he/she received notification of a security alert on unit ACU East. When he/she arrived to the unit, P1 was near a beverage machine and two staff members were attempting to re-direct him/her. S18 stated P1 was accusing S13 of physically assaulting him/her. S18 stated, "I could tell the patient was fixated on a particular individual. I eventually had to put the patient in a hold and walk [him/her] over to the QA room. There were three of us that walked over to QA - me, [S13], and [S14]. Once I realized the fixation on [S13] was not going to stop, I got [S13] out of there. [S13] was in the entry area, but not visible to the patient. The patient kept insisting that [S13] assaulted [him/her] and I kept telling [him/her] that we would get to the bottom of it. We removed [S13] and he/she went back to the floor." S18 stated he/she spoke with the nursing supervisor about the incident and S13 was sent to another unit. S18 stated, "I spoke with the nursing supervisor and we determined it was better to send [S13] to another unit. He went to the CSU unit. [S13] never did the assignment on that unit. [He/She] was on break and then sent home at approximately 4:00 AM."

At 1:00 PM, S18 identified him/herself as the facility's Handle With Care (HWC) trainer. HWC is the facility's training program that teaches staff de-escalation and self-defense techniques. S18 stated, "We failed [S13]. I teach supporting your teammates by 'tapping them out.' It's hard dealing with these types of patients and when you see your teammate beginning to escalate, you can tap them on the shoulder and say 'I need you to remove yourself' or 'Please let me handle this.' It's hard working with this type of patient. You have to remove yourself. This is part of the education. [S13] should have been removed and should have been stopped."

A telephone interview was conducted with Staff #21 (S21) at 1:30 PM. S21 identified him/herself as the nursing supervisor on duty the night of 10/23/23. S21 stated he/she received a call from S15, the Charge RN on duty on ACU East. S21 stated, "[S21] asked to speak with me in the office. [He/She] came in and described an incident with [S13] and the patient. [S21] saw [S13] raise [his/her] hands as if to hit the patient, but didn't actually see [him/her] hit the patient. [S21] said [he/she] was calling CIS and then [he/she] saw them on the floor. I asked [S21] where the patient was. [S21] said [he/she] wasn't sure where the patient was. When I got to the unit, [S13] was at the nurse's station. I spoke with [him/her] in the back [of the break room]. [S13] said the patient attempted to hit [him/her] in the face and [he/she] blocked it, and the patient lost [his/her] balance and fell on the floor. I then went to go speak to [P1]. [P1] stated that [S13] assaulted [him/her]. I came back and spoke with CIS and realized I needed to review the video footage because there were conflicting stories. In the meantime, I made arrangements for [S13] to go to CSU (another unit). I attempted to watch the video, however, the security officer was unable to get into the system. At this point, I called [S13] and told [him/her] to go home. It was around 3:30 AM when I called [S13]."

S21 was asked why he/she did not immediately send S13 home after the incident, but instead, sent him/her to work on another unit around patients after he/she was involved in a physical altercation with a patient. S21 stated, "It was a judgment call. [S13] stated [he/she] was attempting to restrain the patient. Normally I would be able to watch the video, but I wasn't able to this time."

2) On 10/30/2023 at 3:15 PM, Staff #1 (S1), the Assistant Vice President (AVP) of Nursing, stated the facility was in the process of providing staff re-education regarding the procedure staff are expected to follow if an altercation occurs between a staff member and a patient. Upon request of the aforementioned material, the facility was unable to provide documentation of the re-education given to staff.