Bringing transparency to federal inspections
Tag No.: A0145
Based on record review and interview, the hospital failed to ensure a patient (Patient #1) was free from abuse for 1 of 10 patients reviewed. Findings include:
Medical record review revealed that Patient #1 has diagnoses including Autistic disorder and moderate intellectual disability. He was admitted to the facility with increased aggressive behaviors, which included spitting, hitting, hair pulling, and self injurious behavior at his group home. During his stay, Patient #1 required 1:1 staff monitoring, and at times required 2:1 staff monitoring for behavior management.
Human Service Technician /(HST) was interviewed on 7/18/2012 at 9:42 a.m.and stated that on 1/27/2012 between approximately 12:50-1:10 p.m., Patient #1 walked out of his room, and toward HST(M). He approached HST(M) and spit in his face. HST(M) then slapped Patient #1 across the face, with an open palm. She stated that the slap was hard, and that Patient #1 looked shocked. HST(M) immediately apologized to Patient #1. Following the incident, HST(L) walked with Patient #1 to his room. She did not see any redness or marks on his face. HST(M) left the unit, and she reported the incident to her supervisor.
HST(M) was unable to be interviewed during the time frame of the investigation.
HST(M)'s personnel file was reviewed and revealed that he participated in yearly trainings on abuse and neglect. He did not have any abuse or neglect related concerns in his file.