HospitalInspections.org

Based on interview, record review and policy review, the facility failed to provide a safe environment in the Emergency Department (ED), when they failed to:
- Protect one of one patient (#1), when a staff member allegedly physically and verbally abused the patient. (A145).
- Remove one of one alleged perpetrator (Staff U) from patient care (A144).
- Thoroughly investigate alleged verbal and physical abuse for one of one patient (#1) (A145).
- Provide a low bed for one of one high fall risk patient (#1) (A144).
These failures resulted in an unsafe environment for all patients and had the potential to place all patients at risk for abuse and/or injury. The facility census was 137.

These deficient practices resulted in the facility's non-compliance with specific requirements found under the Condition of Participation: Patient Rights.

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

On 06/26/17, after the survey team informed the facility of the IJ, the staff created educational tools and began educating all of the staff by putting into place interventions that protected the patients.

As of 06/28/17, the facility had provided an immediate action plan sufficient to remove the IJ by implementing the following:
- Staff U, Security Officer (alleged perpetrator) was terminated from employment on 06/14/17.
- Staff E, Charge Nurse who failed to escalate the allegation of abuse was coached on 06/11/17 by her Team Leader, reviewed the facility policies, and continued education on 06/13/17.
- A personal development plan (PDP) was initiated on 06/28/17 for Staff E and completed by her next shift.
- Supervisor to perform weekly review of the PDP for three months then monthly for one year.
- All titled leaders to include Charge Nurses, Team Leaders, Managers and Supervisors were re-educated on "Abuse & Neglect" and "Investigation and Reporting" policies.
- 100% of Security Staff and Emergency Department Staff were re-educated on 06/13/17 with a confirmed staff sign in and daily mock scenarios until 100% compliance was achieved.
- 100% of all staff were re-educated on Abuse & Neglect with investigating and reporting.
- The facility ensured that one of the dedicated behavioral health rooms in the ED would have a Behavioral Health Low Bed (low bed) in place.

Based on interview, record review and policy review, the facility failed to provide a safe environment for one of one patient (#1) in the Emergency Department (ED), when they failed to remove an alleged perpetrator (Staff U) from patient care and failed to thoroughly investigate alleged verbal and physical abuse. The facility also failed to provide a low bed for Patient #1 (high fall risk). The failure to remove the alleged perpetrator from patient care had the potential to place all patients at risk for abuse. The failure to place the patient in a low bed, had the potential for an unsafe environment for high fall risk patients in the ED. The facility census was 137.

Findings included:

1. Record review of the facility's policy titled, "Abuse, Neglect and Harassment in the Health Care Setting: Assessment, Investigation and Reporting," dated 05/02/14, showed that any employee working in the hospital who is accused by any source of abuse, neglect or harassment of a patient, shall immediately be excused from all patient care responsibilities anywhere in the hospital or patient care site, during the course of the investigation.

2. Record review of Patient #1's affidavit for admission for a 96 hour hold (lawful admission of a person who exhibits behavior and/or had likelihood of serious harm to himself or others) dated 06/10/17, showed that the patient while in police custody stated:
- "I want to kill myself and I have nothing to live for."
- "My wife left me with nothing."
- "I want to put that gun to my head and blow my brains out."
- "After the police leave I'm going to shoot myself in the fucking head."

3. Record review of Patient #1's history and physical (H&P), showed that:
- The patient presented to the ED on 06/10/17 at 9:28 PM accompanied by law enforcement.
- The patient was suicidal and stated, "I want to die, remember this face, I will be on the news, give me a gun and I will do it right here."
- The patient had a medical history of major depressive disorder with psychotic features.
- The physician's note stated that Patient #1 was very agitated, yelling obscenities and was persistent about wanting to kill himself.

4. Record review of the facility's investigation summary of events showed:
- On 06/10/17 at 9:36 PM Patient #1 was brought to the ED by the local Police Department due to statements of self harm and plans to commit suicide.
- At 10:20 PM the patient was placed in four-point restraints (padded cuffs placed on both arms and legs to prevent the patient from causing harm to themselves or others), due to increased agitation.
- Soon after, patient thrashed his body and overturned the stretcher.
- Multiple staff members entered the room to assist the patient.
- Staff began picking up the stretcher and turning it over when Staff U, Security Officer and Patient #1 were exchanging profanities. Staff U was located at the head of the stretcher.
- Patient #1 was able to free his head and proceeded to attempt to spit in Staff U's face.
- Staff F, Security Officer and Staff G, ED Technician, then witnessed Staff U placing both of his hands around the patient's neck.
- Staff K, RN, then intervened and told Staff U to leave the room.
- Staff U left the room and clocked out at the end of his shift 15 minutes after this event.
- Staff G informed Staff E, Charge Nurse, that Staff U tried to strangle Patient #1.

During an interview on 06/27/17 at 1:30 PM, Staff K, RN, stated that Staff U, Security Officer, was cussing back and forth with Patient #1 and the patient spit in Staff U's face. She stated that she saw Staff U raise his hands and she then grabbed his arm and walked him out of the room.

During an interview on 06/27/17 at 10:12 AM, Staff F, Security Officer, stated that when they picked up the stretcher with the patient, the patient spit at Staff U and Staff U then put both of his hands around the patient's neck. He stated that both thumbs were at the patient's throat. He stated that he had heard the patient gasp for air.

During an interview on 06/27/17 at 11:11 AM, Staff G, ED Technician, stated that when he entered the room the patient and Staff U were exchanging profanity and after they flipped the patient and stretcher back over, the patient spit at Staff U then Staff U put his hands around the patient's neck. Staff G also stated that he informed Staff E, Charge Nurse, of this event.

During a telephone interview on 07/05/17 at 9:08 AM, Staff U, Security Officer, stated that in the heat of the moment he used profanity but did not put his hands on the patient's throat.

5. Record review on 06/27/17 of Staff U's timesheet showed that on 06/10/17 he worked from 12:52 PM until 11:15 PM and he also worked on 06/11/17 from 12:58 PM until 9:06 PM. The facility allowed Staff U, Security Officer to work eight hours the day following the allegation of physical and verbal abuse.

During an interview on 06/27/17 at 9:37 AM, Staff E, Charge Nurse, stated that Staff G did inform her of the event, but they had several behavioral health patients at that time and she did not inform the night shift supervisor. She stated that she did not speak with her supervisor until the next day.

During an interview on 06/28/17 at 9:40 AM, Staff P, ED Physician, stated that she did not perform a post assessment on Patient #1 since she had not been made aware of the event.

During an interview on 06/27/17 at 9:00 AM, Staff C, Director of the ED, stated that she expected her employees to remove any employee that was suspected of abuse until the investigation.

6. Record review of the facility's policy titled, "Patient Safety Algorithm Side B," undated, showed that staff is to maintain a safe-room set up when the patient is at harm to self/others.

7. Record review of Patient #1's H&P, showed that at 9:48 PM the patient was extremely agitated, yelling and making threats to the ED staff and at 9:50 PM the patient rocked the ED stretcher and tipped over the stretcher onto the floor. The staff had placed the patient in restraints and then placed him on a stretcher that was easily tipped over.

The patient was a high fall risk. After the patient tipped the stretcher over, the facility failed to place him in a low safe bed.

During an interview on 06/27/17 at 9:00 AM, Staff C, Director of the ED, stated that Patient #1 should have been in a low bed.

Based on interview, record review and policy review, the facility failed to prevent abuse of one of one patient (#1) in the Emergency Department (ED), when a staff member allegedly physically and verbally abused the patient. This failure had the potential to place all patients in the facility at risk for their safety from abuse or neglect by staff. The facility census was 137.

Findings included:

1. Record review of the facility's policy titled, "Abuse, Neglect and Harassment in the Health Care Setting: Assessment, Investigation and Reporting," dated 05/02/14, showed that:
- Care providers will first address and ensure the safety and well-being of the involved patient.
- Staff will immediately notify a charge nurse and/or department manager when abuse, neglect or harassment of a patient is witnessed, reported or suspected.
- The charge nurse and/or department manager shall immediately notify the attending physician, Administrative Supervisor and Risk Management.

Record review of the facility's policy titled, "Event Reporting," dated 07/2014, showed that when a staff member identifies an "Event", or is involved in an "Event", he/she should first ensure the threat to safety is corrected and then immediately escalate this information through their manager and then the manager will escalate through their chain of command.

2. Record review of Patient #1's affidavit for admission for a 96 hour hold (lawful admission of a person who exhibits behavior and/or had likelihood of serious harm to himself or others) dated 06/10/17, showed that the patient made the following statements while in custody:
- "I want to kill myself and I have nothing to live for. My wife left me with nothing."
- "I want to put that gun to my head and blow my brains out."
- "After the police leave I'm going to shoot myself in the fucking head."

3. Record review of Patient #1's history and physical (H&P), showed that:
- The patient presented to the ED on 06/10/17 at 9:28 PM accompanied by law enforcement.
- The patient was suicidal and stated that he wanted to die, would be on the news, wanted a gun and stated, "I will do it right here".
- The patient had a medical history of major depressive disorder with psychotic features.
- The physician noted that the patient was very agitated, yelled obscenities and was persistent about wanting to kill himself.

4. Record review of the facility's investigation summary of events showed:
- On 06/10/17 at 9:36 PM Patient #1 was brought to the ED by the local Police Department due to statements of self harm and plans to commit suicide.
- At 10:20 PM staff placed the patient in four-point restraints due to increased agitation.
- Soon after patient thrashed his body and overturned the stretcher.
- Staff G, ED technician; Staff K, Registered Nurse (RN); Staff U, Security Officer and Staff F, Security Officer entered the room to assist the patient.
- As staff picked up the stretcher and turned it over, Staff U and Patient #1 exchanged profanities. Staff U was located at the head of the stretcher.
- Patient #1 was able to free his head and proceeded to attempt to spit in Staff U's face.
- Staff F and Staff G then witnessed Staff U place both of his hands around the patient's neck.
- Staff K, RN, then intervened and told Staff U to leave the room.
- Staff U left the room.
- Staff G informed Staff E, Charge Nurse that Staff U tried to strangle Patient #1.
- Staff E did not elevate this abuse.

During an interview on 06/27/17 at 9:37 AM, Staff E, Charge Nurse, stated that Staff G
informed her of the event, but they had several behavioral health patients at that time and she did not inform the night shift supervisor. She stated that she did not speak with her supervisor until the next day.

During an interview on 06/27/17 at 1:30 PM, Staff K, RN, stated that Staff U, Security Officer, was cussing back and forth with Patient #1 and the patient spit in Staff U's face. She stated that she saw Staff U raise his hands and she then grabbed his arm and walked him out of the room. During the event Staff K was located at the foot of the patient's bed.

During an interview on 06/27/17 at 10:12 AM, Staff F, Security Officer, stated that when they picked up the stretcher with the patient, the patient spit at Staff U. Staff U then put both of his hands around the patient's neck. He stated that both thumbs were at the patient's throat. He stated that he had heard the patient gasp for air.

During an interview on 06/27/17 at 11:11 AM, Staff G, ED technician, stated that when he entered the room the patient and Staff U were exchanging profanity and after they flipped the patient and stretcher back over, the patient spit at Staff U then Staff U put his hands around the patient's neck. Staff G stated that he informed Staff E, Charge Nurse, of this event.

During a telephone interview on 07/05/17 at 9:08 AM, Staff U, Security Officer, stated that in the heat of the moment he used profanity but did not put his hands on the patients' throat.