HospitalInspections.org

The Condition of Participation: Patient Rights was out of compliance.

Findings included:

Based on interviews and record reviews, the Hospital failed to provide care in a safe setting for two of 13 sampled patients (Patient #1 & Patient #12), when Patient #1 was tackled to the ground by Security Guard #1 and Patient #12 was dragged down a hallway on his/her back by Security Guard #1.

Cross Reference: 482.13(c)(2): Patient Rights: Care in a Safe Setting (0144).

Based on records reviewed, documents reviewed, and interviews, the Hospital failed to provide care in a safe setting for two patients (#1 and #12) out of a sample of 13 patients.

Findings included:

Review of the Hospital ' s policy titled ' Reporting of Allegations of Patient Neglect or Physical or Sexual Abuse or Assault ' , effective 7/14/20, indicated that any employee or member of the Medical Staff who witnesses or receives an allegation of sexual, or physical abuse, neglect or assault of any patient must immediately ensure the safety of that individual and must immediately make contact with the Facility Administrator On Call (AOC) or designee.

Review of the Hospital ' s Policy titled Sentinel Event/Serious Reportable Event, dated 2/17/22, indicated the Hospital would improve patient care by reviewing and responding to Sentinel Events as set forth by The Joint Commission (TJC). The Policy indicated the Hospital would:

Utilize a patient safety reporting system (Midas) to identify, address document, and report to their appropriate supervisor, and senior Director of Quality and Patient Safety all potential Sentinel Events.

Conduct a timely, thorough and credible Root Cause Analysis within 14 days of the event being identified and develop an action plan with measurable intermediate and high strength human factor action items designed to implement improvements to reduce risk.

Report a serious reportable event (SRE)/Sentinel Event in conformance with the requirements of state law and regulations.

Review of the TJC ' s, Comprehensive Accreditation Manual for Hospitals, dated January 2024, defines a Sentinel Event as a patient safety event (not primarily related to the natural course of a patient ' s illness or underlying condition) that reaches a patient and results in death, severe harm (regardless of duration of harm), or permanent harm (regardless of severity of harm).

1.) Patient #12 was admitted to the Hospital ' s Child Development Unit (CDU) in December 2022 with diagnoses including oppositional defiance disorder (ODD), attention deficit hyperactivity disorder (ADHD), and aggression.

Review of Hospital Compliance Investigation Memo dated 3/8/24 indicated that on 3/5/24 two social work interns notified the Director of Operations of an allegation made by Patient #12 ' s Family Member, alleging physical/verbal abuse of Patient #12 by a staff member. The Memo indicated as part of the abuse allegation, Leadership requested Security Guard (SG) #1 be placed on another unit/assignment until security footage was reviewed and completed a review of Patient #12 ' s Behavioral Health Unit ' s security camera video on 3/2/24 at 5:08 P.M., which depicted Security Guard (SG) #1 dragged Patient #12 along the floor on his/her back by his/her arms over his/her head for several feet before placing him/her into the seclusion room. The Memo indicated that two staff members were present observing this event and that dragging a patient along the floor was not proper technique for staff to use at the Hospital. The Memo indicated that the Hospital Compliance Officer (HCO) discussed findings with the Director of Operations, Director of Nursing and Market Executive Director and that all agreed staff retraining was needed.

Review of Hospital ' s grievance correspondence to Patient #12 ' s Family Member, dated 3/8/24, indicated the allegation was substantiated that Security Guard #1 was rough during a restraint of Patient #12 on 3/2/24 at approximately 5:00 P.M.

On 8/22/24 at 3:13 P.M., The Hospital Compliance Officer assisted Surveyor #1 and #2 review the security camera video from Patient #12 ' s unit on 3/2/24. The video depicted the following:

Patient #12 put him/herself on the floor and did not appear to be a threat to him/herself or others.

SG #1 took Patient #12 ' s arms and held them over his/her head and began dragging Patient #12 down the hallway on his/her back for about six feet and brought him/her through a doorway (into the seclusion room).

Another security guard and a nurse witnessed SG#1 drag Patient #1 along the ground and did not intervene to stop SG#1 and ensure Patient #12 ' s safety.

The Hospital was unable to provide any documentation during the Survey to support staff retraining that was completed after an investigation substantiated Security Guard #1 was rough and used improper techniques when he dragged Patient #12 down the hallway on his/her back with two staff members present to witness the event and failed to intervene and report the event to Hospital Leadership.

During an interview on 8/21/24 at 9:09 A.M., the Hospital Compliance Officer (HCO) said he investigates abuse allegations for the Hospital. The HCO said he was made aware of the dragging allegation because Patient #12 ' s relative had reported it to a Social Work intern a few days after the event, and further said that none of the staff who witnessed Patient #12 being dragged by Security Guard #1 reported it to their supervisor. The HCO said Hospital policy was that any potential abuse or assault must be reported within 24 hours by staff. The HCO said he reviewed the security camera footage of 3/2/24 as part of his investigation and said this was not a good event as Security Guard#1 used inappropriate techniques and it was determined that Security Guard #1 should receive re-education as a result of this inappropriate restraint event. The HCO said this re-education was completed by the Director of Security.

During an interview on 8/21/24 at 10:23 A.M., the Director of Security said his job includes scheduling staff, onboarding, discipline, responding to calls and video review. The Director of Security said there was specific training called Crisis Prevention & Intervention (CPI) that teaches security officers de-escalation techniques and use of approved physical holds for patients. The Director of Security said it was not appropriate or an approved use of physical hold to drag a patient on the ground. The Director of Security said he was familiar with Security Guard #1 but was unable to provide any documentation that any re-education was completed with Security Guard #1 after the event in which the Security Guard dragged Patient #12 down the hallway.

During an interview on 8/22/24 at 10:27 A.M., the Nurse Educator said all staff and security guards are trained in CPI techniques, and security might have more advanced training. The Nurse Educator said dragging a patient on their back was not an acceptable technique. The Nurse Educator said nursing staff that witness this type of act need to speak up and are ultimately responsible for their patients. She said nursing should intervene in the moment and also report up to supervisors. The Nurse Educator said she was not involved in any re-education as a result of this event.

During an interview on 8/22/24 at 2:25 P.M., the Market Director for Clinical Quality Improvement said the Hospital did not complete a Midas (incident) report or a root cause analysis for the event on 3/2/24 in which Security Guard #1 dragged Patient #12 down a hallway; additionally, the Hospital was unable to provide any evidence of corrective actions, such as staff re-education, implemented by the Hospital to prevent a like occurrence.

2.) Patient #1 was admitted to the Hospital ' s Child Development Unit (CDU) in February 2024 with diagnoses including anxiety disorder and disruptive mood dysregulation.

Review of Hospital Compliance Investigation Memo dated 4/1/24 indicated that on 3/20/24 the Director of Operations and Market Executive Director of Behavioral Health contacted the Hospital Compliance Officer (HCO) to report a rough patient restraint from 3/15/24, which was found during administrative video review. The Memo indicated that during an interview, Patient #1 reported being tackled by Security Guard #1, which knocked Patient #1 and a staff member to the floor causing both to hit their heads. Further, Patient #1 alleged he/she was pushed onto the counter and his/her face was pushed against the counter causing it to bleed.

The Investigation Memo indicated that it was substantiated that Security Guard #1 ' s restraint was rough and did not follow CPI protocol; it was substantiated that it was likely Patient #1 hit his/her nose on the floor or the counter during the restraint; additionally, it was substantiated that witnessing staff did not report Patient #1 ' s allegation of abuse by Security Guard#1 in a timely manner, in accordance with the Hospital ' s Abuse Policy.

Review of the Hospital ' s Internal Investigation, undated, indicated there was evidence of complaints against Security Guard #1, it was reported that staff felt he was using excessive force with Patient #1 as well as taunting the Patient verbally which increased the Patient ' s chances of escalating. It was determined that Patient #1 was put in a physical hold, which resulted in him/her being pushed into the nursing counter and that the Patient had a bloody nose. It was determined Security Guard #1 should be terminated and recommended that staff and leaders be re-educated on escalating these types of safety events immediately to the nursing supervisor as well as completing a safety report to ensure events are being investigated and managed in a timely manner.

On 8/21/24 at 9:43 A.M., The Hospital Compliance Officer assisted Surveyor #1 and #2 to review the security camera video from Patient #1 ' s unit on 3/15/24. The video depicted the following:

Patient #1 entered the RN station from a door (to the seclusion room). Patient #1 was standing there with other staff members for a few seconds and did not appear to be a harm or potential harm to him/herself or others.

Patient #1 placed his/her hands up in the air and Security Guard #1 charged at Patient #1 and tackled Patient #1 down to the ground. Security Guard #1 ' s hands remained on the neck of Patient #1 shirt and Security Guard #1 picked Patient #1 up by the neck of his/her shirt and forcibly moved Patient #1 from one side of the RN station to another.

The HCO said that when the Patient was moved to the other side of the station, out of full video view, Security Guard #1 bent Patient #1 over the counter with his/her face against the counter of the RN station and put his/her hands behind his/her back.

During an interview on 8/21/24 at 9:09, the HCO said Security Guard #1 was terminated as a result of event on 3/15/24. The HCO said in this instance, the witnessing staff did not report Security Guard #1 charging at and tackling Patient #1. The HCO said from his investigation and review of the video footage, Security Guard #1 charged into the RN station, tackled Patient #1 and knocked the Patient and nurses to the ground. The HCO said video review showed Security Guard #1 applying a forceful restraint likely causing Patient #1 ' s nose to bleed, either from being knocked down or the restraint. The HCO said this was an undue use of force by Security Guard #1 and he was not using proper technique. The HCO further said there was a delay in investigating, because staff did not report this incident and said Security Guard #1 could have been working in the days between the event and the investigation, due to this delay in reporting. The HCO said Hospital policy is that any potential abuse, neglect or assault incidents should be reported within 24 hours.

During an interview on 8/21/24 at 11:56 A.M. the Director of Operations said she was reviewing the restraint event via security camera video and observed Security Guard #1 tackling Patient #1 and immediately reported the event to the Hospital Compliance Officer and the Market Director of Behavioral Health. She said that she reviewed the footage a few days after the event occurred and that no staff reported the Security Guard ' s actions to her or any other manager. The Director of Operations said she doesn ' t recall anything done specifically after this event regarding staff education or other corrective actions but said the Security Guard was asked not to return to the Hospital.

During an interview on 8/21/24 at 3:14 P.M., CDU Nurse #1 said she was working the night of the event and that after a movie, some of the kids started to escalate. The CDU Nurse said that Patient #1 had come into the RN station from the seclusion room and said that the Patient had been aggressive but said that the Security Guards were also aggressive, and that Patient #1 ended up with his/her face down on the counter in the RN station and ended up with a bloody nose. The CDU Nurse was unsure of any follow-up or re-education done after this event but said she hadn ' t received any.

During an interview on 8/22/24 at 10:27 A.M., the Nurse Educator said nurses are ultimately responsible for their patients and if they witness any potential abuse or assault toward a patient, they should intervene in the moment and also report up to supervisors. The Nurse Educator said tackling a patient was not appropriate, and if nursing witnessed that they should intervene in the moment and then report it. The Nurse Educator also said that putting a patient face down with hands behind back was not appropriate. The Nurse Educator said she did not participate in any re-education after this event 3/15/24.

The Hospital failed to implement corrective actions to prevent a like occurrence from happening after it was substantiated that staff witnessed Security Guard #1 tackle Patient #1 to the ground.