HospitalInspections.org

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Based on observation, interview, and record review, the facility failed to ensure that patients passing through the elevator lobby of the second floor of the HCPC building were provided a safe setting. More specifically, the facility failed to ensure that staff members in Dietary Services accounted for their aprons while in patient care areas.

Findings included:

During a tour of the psychiatric units on 12.17.2025 at 1:30 PM with Staff B (Nurse Manager), a black apron was found on top of the metal cabinet that housed the emergency evacuation device. The metal cabinet was in the elevator lobby on the second floor. A hospital staff member (Staff J) was observed walking through the lobby area. She walked over to retrieve the apron.

Further observation of apron showed it to be a black poly-cotton blend apron with a neck strap and two waist ties.

In an interview with Staff J, she identified herself as a "cook" in the Dietary Services Department, adding that she was not responsible for the apron being on the top of the metal cabinet. She stated the apron should not be on the cabinet because it was "unsanitary." She removed the apron and exited the lobby.

In an interview with Staff B (Nurse Manager) on 12.17.2025 at 1:30 PM, he stated that not only was the apron "unsanitary" and an "infection control issue," it was also a potential "ligature risk." He also stated that by placing "a heavy item in the apron, it could be used as a weapon." Staff B demonstrated how a heavy object could be placed in the apron to create an improvised impact weapon. He concluded by saying that patients passing through the lobby area on their way to the dining hall could potentially have access to the apron.
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Based on record review and interview, the facility failed to ensure patients' right to be free from abuse, as shown by:

a) Staff (RN Staff #Z) cursing at a patient, inciting aggression, then physically fighting with a patient (Patient #1);

b) Failing to protect other patients by allowing the staff member (RN Staff #Z) to return to work with patients after abuse allegations were not fully investigated, and;

c) Not having a clear policy for their abuse investigation process that protected patients from staff who were alleged perpetrators of abuse, such as removing the staff from direct patient care.


Findings included:


Review of facility policy #PR-0002 titled "Patient Rights, Responsibilities, and Limitations on Patient Rights" dated 3/5/24 showed that patients had the right to be free from mistreatment and abuse.

Review of facility policy #PR-0004 titled "Staff Responsibilities and Actions Associated with Suspected Abuse, Neglect, or Exploitation" dated 3/4/24 showed the following: Class II abuse was described as striking or pushing a patient, regardless of it resulting in injury; Class III abuse was described as staff cursing at a patient.



A) RN Staff #Z incitement and abuse of Patient #1:

Review of facility incident report showed that on 12/5/25 at 1:56 pm while in an outside courtyard of the Dunn building (DCB) during a fresh air break, Patient #1 "eloped" by crossing a gate and went into a different courtyard (HCPC) which was off limits, despite her having a 1:1 close sitter, who failed to prevent this. RN Staff #Z, a nurse from HCPC became involved, used derogatory language which escalated the patient, and the patient attempted to strike the nurse and grab her hair.

However, facility began an investigation, and it was revealed that Patient #1 and RN-Staff #Z had a verbal and subsequent physical fight, after RN Staff #Z incited the patient to become aggressive by cursing at her and not removing herself from area. RN Staff #Z hit the patient back during the fight and had to be pulled off the patient and restrained by other staff.

Although video review of the event with DON Staff #A on 12/17/25 at 12:20 pm failed to capture the entire incident due to blind spots, numerous statements from onsite witnesses to the event showed that RN Staff #Z verbally and physically abused the patient:

Portions of written statements via emails from Psychiatric Technicians (PTs) dated 12/5/25, who were witnesses to the incident showed the following:

PT Staff #U wrote that things were under control with Patient #1 and they were walking back to the DCB courtyard after techs calmed her down. The patient stated she did not want the nurse near her (RN Staff #Z) and the nurse "out loud in front of everyone" called her a bitch.

PT Staff #W wrote that the nurse told the techs to put their hands on the patient but the techs were able to verbally deescalate the patient who became cooperative and was walking back to the DCB courtyard on her own. The patient said several times she did not want the nurse near her. The nurse then called her a bitch twice. The patient and nurse started fighting physically and the nurse punched the patient back. They were separated after the patient pulled the nurse's hair, but then the nurse "charged" back at the patient. Staff #W tried to hold the nurse back, who said to her "get the f*** off" of her, and she was going "to "f*** her up" (hurt the patient), and also said "I told y'all to put your hands on the patient".

PT Staff #X wrote that the techs were able to get the patient to walk back to the DCB courtyard "peacefully" but when they crossed the gate, the nurse was there which agitated the patient. The nurse called the patient a bitch and it started a fight between the two of them.

PT Staff #Y wrote that the nurse and patient were cursing at each other. While the patient was walking back to the DCB courtyard, the nurse kept instructing the techs to put their hands on the patient but there was no need to because the patient "wasn't attacking anyone". The nurse kept "antagonizing" the patient and the patient said she did not want that nurse near her. The techs asked the nurse to move away but she refused. The patient threatened to hit the nurse if she didn't move, then the nurse called her a bitch. A fight broke out and the nurse "fought the patient back". The techs "screamed" at the nurse to stop but "she (the nurse) didn't care" and had to be pulled off the patient.

Portions of verbal statements from PTs made to Patient Advocate Staff #S on 12/10/25 showed the following:

PT Staff #R said the situation became under control and the patent began following staff directions, but the nurse refused to remove herself from the area and insisted on restraining the patient. The nurse was "calling the patient out" and refusing to move away from a gate that led back to the DCB courtyard, which was the pathway for the patient coming back. A fight between the nurse and patient ensued and the entire group of PTs who were there had to physically restrain the nurse. PT Staff #R also stated that the fight was preventable.

PT-Staff #T said that he heard the nurse and patient cursing at each other. As staff were taking the patient back through the gateway, with the patient cooperating, the nurse stood in the direct path of the patient which was the primary cause of the patient's aggression escalating, sparking the fight. He also stated that all the other PTs present asked the nurse to stand elsewhere but she would not listen to them.

PT Staff #V said that the patient told the nurse to go away, and the nurse said, "I'm not moving, I'll stand right here". The patient became mad and pulled the nurse's hair. A physical fight followed and several techs had to hold the nurse back, telling her it wasn't worth her license. PT Staff #V also said that the nurse made the patient mad and the patient could have been fully deescalated without a restraint.

In an interview on 12/17/25 at 3:50 pm, Patient Advocate Staff #S stated that allegations of verbal abuse against RN Staff #Z were substantiated. However, allegations of physical abuse were inconclusive due to the video of the altercation not being completely visualized due to a blind spot.

Although there was no audio sound in the video tapes, the facility confirmed verbal abuse based on numerous verbal and written statements from direct witnesses. However, these same witness statements also described physical abuse as well.


B) Facility failing to protect other patients:

In an interview on 12/17/25 at 3:55 pm, HR Director Staff #AA and DON Staff #A stated the investigation was still ongoing and administrative staff were going to discuss investigation findings today, adding that the full investigation was not yet complete. When asked if RN Staff #Z was allowed back on the unit to work, they stated that she had just returned to work today. Staff #AA then stated that this should not have happened and RN Staff #Z should have been out on administrative leave, adding that she should not have been allowed to return to work today.


C) Policy to protect patients from staff accused of abuse:

Further review of facility abuse policy #PR-0004 titled "Staff Responsibilities and Actions Associated with Suspected Abuse, Neglect, or Exploitation" dated 3/4/24 failed to show that staff were either temporarily suspended or removed from direct contact with patients during an investigation if they allegedly abused a patient. The policy described the various definitions of abuse and the abuse investigation process. However, it did not describe the action of suspending or removing a staff member from being with patients during the investigation process.

In two separate interviews on 12/17/25 at 4:40 pm and 4:50 pm, PI Director Staff #D stated there was no policy addressing what to do with staff members who were accused of abusing patients during the facility investigation. When asked specifically if there was any formal policy or procedure that suspended or removed the accused staff member from contact with patients during abuse investigations if the staff was the alleged perpetrator, Staff #D stated there was nothing the facility had that addressed this and she stated this was confirmed with HR Director Staff #AA.