HospitalInspections.org

The CoP of Patient Rights was out of compliance.

Based on tour of the hospital, clinical record reviews, review of Hospital documentation, policies and interviews, for 1 of eighteen sampled patients (Patient #5) who was reviewed for abuse,

The hospital failed to ensure one patient was protected from abuse, failed to ensure staff immediately reported the observed abuse, failed to utilize the chain of command when the staff member continued to work placing other patients at risk following the observation of abuse, failed to ensure Leadership was immediately notified of the observed abuse, failed to notify the local law enforcement agency, and failed to ensure timely notification of other state agencies in accordance with the hospital's policy. The hospital failed to ensure all staff were re-educated on reporting abuse and the investigative process resulting in Immediate Jeopardy.

Please refer to A-145 Patient Rights: Free from abuse and harassment - 482.13 (c) [3]

Based on tour of the hospital, clinical record reviews, review of Hospital documentation, review of policies and interviews, for 1 of eighteen sampled patients (Patient #5) who was reviewed for abuse, the hospital failed to ensure one patient was protected from abuse, failed to ensure staff immediately reported the observed abuse, failed to utilize the chain of command when the staff member continued to work placing other patients at risk following the observation of abuse, failed to ensure Leadership was immediately notified of the observed abuse, failed to notify the local law enforcement agency, and failed to notify other state agencies in accordance with the hospital's policy. The hospital failed to ensure all staff were re-educated on reporting abuse and the investigative process resulting in Immediate Jeopardy. The findings include:

Patient #5 was admitted to the hospital with diagnoses to include oppositional defiant disorder, paranoid personality traits, and anger dyscontrol (recurrent attacks of uncontrollable rage).

The Initial Psychiatric evaluation dated 6/30/23 identified Patient #5 endorsed no suicidal ideation, no homicide risk, displayed depressed emotional mood, with guarded interactions, with a Broset violence checklist score of 1 (range 0-6 with 6 indicating highest risk for exhibiting violent behaviors). The evaluation note identified the plan included admission to the adolescent unit, patient to participate in individual and group therapy, start home medications, and to adjust medications.

A Behavioral health progress note dated 7/1/23 at 7:34 AM identified Patient #5 was tolerating medications, denied suicidal and homicidal ideations, and was cooperative but with little engagement.

A plan of care RN note dated 7/1/23 filed at 4:18 PM identified Patient #5 refused to visit with his/her family member, was pacing, guarded, and apprehensive, and identified patient was medicated and given a squeeze ball (used to alleviate stress).

Review of a hospital document dated 7/1/23 at 9:46 PM noted Patient #5 was opening his/her door and throwing stuff at staff when Mental Health Worker (MHW) #1 pushed the patient from the doorway onto his/her bed. The report identified Patient #5 did not step forward to staff.

Review of the camera footage of the events of 7/1/23 with the Director of Nurses on 7/12/23 at 9:45 AM identified that on 7/1/23 at 9:46 and 15 seconds PM, MHW #1 and an unidentified patient were seated in the common area and MHW #2 was identified in the room across from Patient #5's room. At 9:46 PM and 23 seconds an object was seen coming from Patient #5's room. At 9:46 PM and 26 seconds MHW #1 got up from seated position and walked towards Patient #5' room when a second object was seen coming out of Patient #5's room. MHW #1 entered Patient #5's room at 9:46 PM and 32 seconds and exited the patient's room at 9:46 PM and 39 seconds, at this time MHW #2 remained present in the room with full view of Patient #5's room.

Interview with MHW #2 on 7/12/23 at 11:05 AM identified on the day of the incident he was admitting a patient in the fishbowl (room with windows looking out on to common spaces and patient rooms) when he identified objects being thrown from Patient #5's room into the common hallway. MHW #2 identified the objects were books and papers and did not include objects that could cause harm. MHW #2 stated he observed MHW #1 enter Patient #5's room, place his arms on the patient's body, stepped forward, extended his arms and the patient fell on the bed. MHW #2 identified that at approximately 10:15 - 10:20 PM as soon as he completed the admission process, he reported his observations to RN #1 (Nursing supervisor) and completed a written report of the incident. MHW #2 identified that according to the Crisis Prevention Institute (CPI) training provided by the hospital staff should not place hands on a patient unless this was utilized as a calming intervention not an act of aggression.

Interview with MHW #1 on 7/6/23 at 12:05 PM stated he observed Patient #5 throw a ball out his/her room and MHW #1 stated he approached the patient's room to identify if Patient #5 had additional items to throw out of the room. MHW #1 identified Patient #5 was standing by the door to the room and was swearing and moving his/her arms. Although MHW #1 identified Patient #5 did not charge at him and did not attempt to hit him, MHW #1 stated he pushed the patient onto the bed as the patient was strong. MHW #1 indicated he did not do anything wrong as the patient was a threat.

An interview with RN #1 (Nursing Supervisor 7:00 PM to 7:00 AM 7/1 to 7/2/23) on 7/6/23 at 11:45 AM identified MHW #2 informed her that he observed MHW #1 push Patient #5 forcefully causing the patient to fall back into the bed. RN #1 indicated she asked MHW #2 to file a report, identified she sent an email to the Director of Nursing, the Unit Manager and to Human Resources. Although RN #1 identified that when there was an allegation of abuse the process was to talk with all staff on the shift and to decide on whether to take immediate action, RN #1 stated MHW #1 had been a problem and she wanted Management to handle the issue. RN #1 indicated she was not aware MHW #1 worked for the remainder of the shift and identified she should have sent MHW #1 home, but she had 6 incidents in the hospital and was very busy.

Interview with Patient #5 on 7/6/23 at 11:30 AM identified s/he did not feel good after the incident when s/he was pushed unto his/her bed by a staff.

An interview and personnel file review with Director #1 and Employee and Labor Relations Consultant on 7/6/23 at 9:00 AM identified an email describing the incident was sent to the team on 7/2/23 at 2:11 AM. However, Director #1 identified she was not aware of the incident until Monday 7/3/23 at which time Mental Health Worker (MHW) #1 was placed on administrative leave and a report was made to the Department of Children and Families (DCF). Director #1 stated that MHW #1 worked on 7/1 - 7/2/23 7:00 PM to 7:00 AM and returned to work on 7/2 - 7/3/23 from 3:00 PM to 8:13 AM. The employee and labor relations consultant identified that immediate action should have been taken at the time of the incident to include nursing supervisor making the decision to put MHW #1 out on leave, escalate issue to the on-call director of nursing, and filing a DCF report.

Interview with the Director of Quality on 7/6/23 at 11:00 AM identified she was made aware of the incident on 7/3/23 after the weekend when she reviewed the incident report. The Quality Director identified that the expectation was for the Nursing supervisor on shift to escalate the incident by making a phone call, not sending and email, to the Director of Nursing.

An interview with Manager #1, Quality Director, Vice President of Operations and employee and labor Relations Consultant on 7/6/23 at 2:00 PM identified re-education of staff was not initiated at the time of the interview (5 days after the incident) as the hospital investigation of the incident was not yet completed. The team reported that interview with MHW #1 and review of the camera footage were not yet completed as the Director of Nursing and Director of Environmental Service were on vacation.

An interview with Educator #1 (CPI trainer) on 7/12/23 at 10:46 AM identified that in a crisis situation the unlicensed staff, to include the mental health worker, should get directions from a licensed staff before intervening. Educator #1 identified that if the unlicensed staff was alone and there is a need to separate patients in a crisis, the unlicensed personnel can separate patients and get a licensed staff as soon as possible. The educator identified that if the staff feels threatened, the staff should get support. Educator #1 identified steps to be taken by staff in a crisis situation included to stay rational, keep cool, be self-aware, and extract self from the situation.


The hospital failed to ensure Patient #5 was protected from abuse, failed to ensure MHW #2 immediately reported abuse by MHW#1 to the Supervisor, RN Supervisor #1 failed to remove MHW#1 from patient care to prevent further abuse and failed to notify on call Administration of the observed abuse. Although MHW #1 was removed from duty two days following the abuse once known, the hospital failed to reeducate staff to immediately report abuse and implement measure to prevent further abuse. The hospital failed to notify local law enforcement as mandated reporters and failed to notify another State Agency timely of abuse. As a result of these failures, Immediate Jeopardy was identified.

Review of the policy entitled, Complaints of Inappropriate Colleagues behavior Involving a Patient, directed if the incident was outside business hours to notify covering nursing supervisor/nurse coordinator. The policy further directed to immediately complete a preliminary review of the specifics of the allegation and to establish any facts known at the time of the review including identification of other potential witnesses and prompt notification should be made to the attending physician, Regional public safety director, nurse supervisor, and administrator on call. The policy further directed the Colleague may need to be placed on administrative leave depending on the circumstances. The policy identified inappropriate behaviors include physically or mentally abusive treatments to patients, co-workers, or other stakeholders.

Review of the policy entitled, Abuse and Neglect of Children, identified that all Hospital personnel are mandated reporters and directed to report all known or suspected abuse and neglect to the Department of Children and Families (DCF) within 12 hours of being made aware or the suspected abuse or neglect. The policy further directed that any report in which the allegation of abuse or neglect involves potential wrongdoing by hospital staff will be escalated to the Director of Nursing, identified the director would escalate further to Vice President of Operations and Director of Quality.

The immediate Jeopardy template was presented to the Director of Quality on 7/6/23 at 4:55 PM.
The Hospital provided an immediate corrective action plan on 7/6/23 to include: One on one coaching on escalation process of alleged cases of abuse, neglect, and other potentially harmful events by the Nurse Manager to each individual nursing supervisor. All employees who work within inpatient settings, including Physicians, Nurses, Clinicians, Mental Health Workers, Ancillary Staff (Facilities, EVS, Dietary) will receive education prior to their next scheduled shift on the "Complaints of Inappropriate Colleague Behaviors with a Patient" policy.

On 7/7/23 during the onsite visit, the action plan was verified as implemented and Immediate Jeopardy was removed at 12:00PM.