HospitalInspections.org

A. Based on document review and interview, it was determined that for 1 of 2 abuse allegation reviewed for Pt. #1, the Hospital failed to ensure patient rights to be free from all forms of abuse, by initiating an abuse investigation, notifying the required individuals, and completing an incident report immediately upon notification of an allegation of abuse.

Findings include:

1. The Hospital's policy titled, "Unusual Occurrence Reporting: Patient and Visitor" (dated 10/2/2020), was reviewed on 4/6/2021, and required, "...When any occurrence, event or situation takes place which is inconsistent with the care and treatment of a patient it must be reported to the Manager of the department providing service to the patient at the time of the incident. A record of the complete facts must be immediately filled out by the employee who observed the alleged occurrence on a Confidential Repot of Incident Form..."

2. The Hospital's policy titled, "Reporting of Alleged Patient Abuse and Neglect" (dated 10/1/20), was reviewed on 4/6/2021, and required, "All reports of abuse, neglect or death must be reported immediately to the Director of Performance Improvement/Risk Management, or designee and the Director of the Department in which the alleged report of abuse, neglect or death occurred..."

3. The clinical record for Pt #1 was reviewed on 4/5/2021. Pt #1 presented to the ED (emergency department) on 10/4/2020, with a diagnosis of schizoaffective disorder (serious mental illness). Pt #1 was admitted to the 3 East Behavioral Health Unit on 10/4/2020, transferred to the Medical Unit 5 West on 10/4/2020, and then transferred back to the 3 East Behavioral Health Unit on 10/6/2020.

- Pt #1's Nursing Note, documented by a 3 East RN (E #12), dated 10/9/2020, included, "Patient has the potential risk to harm others ...Patient has complaints of 'headache' from getting my head slammed into the floor, rated a '10' on a [pain] scale from 1-10 [10 being the highest]...Patient denies hallucinations and auditory hallucinations ..." The clinical record lacked notification of an abuse allegation to the Unit Director, Risk Manager, or House Supervisor. The clinical record lacked an incident report or investigation for this abuse allegation.

4. On 4/6/2021 at 1:40 PM, an interview was conducted with the Behavioral Health Unit Director (E #2). E #2 stated that any abuse allegation should be investigated, whether unfounded or not. E #2 confirmed that there was no incident report or investigation done for the abuse allegation that was documented on 10/9/2020.

B. Based on document review and interview, it was determined that for 1 of 1 (Pt #1) investigation of abuse allegations reviewed, the Hospital failed to ensure patient rights to be free from all forms of abuse, by thoroughly completing an abuse allegation and maintaining a complete investigation file.

Findings include:

1. The Hospital's policy titled, "Reporting of Alleged Patient Abuse and Neglect (dated 10/1/20), was reviewed on 4/6/2021, and required, "...[Hospital] shall maintain a local investigative case file containing the investigative report and all investigatory materials. This includes all evidence such as photographs, interview statements, and records...When accused persons and potential witnesses are separate pursuant to...above, [Hospital may require written statements from each person, detailing what he or she knows about the alleged abuse/neglect or other incident...The statement shall be obtained immediately upon the report of an allegation, but no later that two working days from the report if the person providing the statement was not on duty at the time..."

2. The clinical record for Pt# 1 was reviewed on 4/5/2021. Pt #1 presented to the ED (emergency department) on 10/4/2020, with a diagnosis of schizoaffective disorder (serious mental illness). Pt #1 was admitted to the 3 East Behavioral Health Unit on 10/4/2020, transferred to the Medical Unit 5 West on 10/4/2020, and then transferred back to the 3 East Behavioral Health Unit on 10/6/2020.

3. An incident report for an event that occurred 10/14/2020 involving Pt #1, included, "On 10/14/20: Review of [video] footage showed patient being re-directed to come out of the shower several times by the MHS [mental health specialist/E #10]. The patient refused redirection after which assistance from other team members was requested. The patient exited the shower room unclothed and was then provided with towels to cover up before going out into the milieu. The patient then refused further direction and sat down on the floor at with the time the MHS [E #10] dragged the patient into the patient into the quiet room and kicked her in the lower extremities, closed and locked the quiet room door ..." The investigation included summarized interviews from the staff involved and who witnessed the event. However, there were no written witness statements included in the incident report. The incident report also lacked a final determination of the allegation, whether it was substantiated or not. The report also lacked any re-education or inservice given to staff following the event.

4. On 4/6/2021 at 1:40 PM, an interview was conducted with the Behavioral Health Unit Director (E #2). E #2 stated that regarding the incident on 10/14/2020, with Pt #1, he reviewed video footage. E #2 stated that the footage showed the MHS (E #10) trying to redirect Pt #1 when she got out of the shower. E #2 stated that the patient sat on the floor without clothes on. E #2 stated that E #10 took a towel and dragged the patient across the floor to the Quiet Room. E #2 stated that once the patient was placed in the Quiet Room, the patient put her legs in the doorway. E #2 stated that at that point, E #10 kicked Pt #1's legs to get them out of the doorway. E #2 stated that according to CPI training, the MHS should have called for help. E #2 stated that this incident was substantiated. E #2 stated that E #10 was suspended for 3 days. E #2 stated that it was re-enforced to E #10 to think about actions that could be mis-interpreted the wrong way if different people view it. E #2 stated that the investigation should indicate if it was substantiated or not. E #2 confirmed that there were no written witness statements available, and stated that staff was reeducated, but the reeducation was not documented, other than for E #10.

C. Based on document review and interview, it was determined that for 1 of 1 (Pt #1) investigation of abuse allegations reviewed, the Hospital failed to ensure patient rights to be free from all forms of abuse, by not ensuring that the patient was protected following an abuse allegation.

Findings include:

1. The Hospital's policy titled, "Reporting of Alleged Patient Abuse and Neglect (dated 10/1/20), was reviewed on 4/6/2021, and required, " If the allegation constitutes abuse or neglect... the [Hospital] shall: Ensure the immediate care and protection of the victim...Remove the accused employee from direct care when there is credible evidence supporting the allegation of abuse or neglect..."

2. The clinical record for Pt# 1 was reviewed on 4/5/2021. Pt #1 presented to the ED (emergency department) on 10/4/2020, with a diagnosis of schizoaffective disorder (serious mental illness). Pt #1 was admitted to the 3 East Behavioral Health Unit on 10/4/2020, transferred to the Medical Unit 5 West on 10/4/2020, and then transferred back to the 3 East Behavioral Health Unit on 10/6/2020.

3. The incident report for the event that occurred on 10/14/2020, included, "On 10/14/20: Review of [video] footage showed patient being re-directed to come out of the shower several times by the MHS [mental health specialist/E #10]. The patient refused redirection after which assistance from other team members was requested. The patient exited the shower room unclothed and was then provided with towels to cover up before going out into the milieu. The patient then refused further direction and sat down on the floor at with the time the MHS [E #10] dragged the patient into the patient into the quiet room and kicked her in the lower extremities, closed and locked the quiet room door ..." The incident report indicated that E #10 was suspended pending investigation. E #10 was suspended for 3 days. Following suspension, E #10 was assigned to care for the patient following the abuse allegation on 10/26/2020, 10/27/2020, 10/31/2020, and 11/1/2020.

4. On 4/7/2021 at 12:35 PM, a phone interview was conducted with E #2. E #2 stated that E #10 should not have been taking care of Pt #1 during Pt. #1's hospitalization.