HospitalInspections.org

The Condition of Patient Rights has not been met.

Based on clinical record reviews, review of hospital surveillance camera footage, review of hospital documentation and interviews for two of two sampled patients (Patients #1 and #11) reviewed for staff to patient abuse, the hospital failed to ensure that all categories of direct care and supervisory staff with access to behavioral health patients were reeducated following a substantiated patient to staff abuse with patient injuries, leading to a subsequent staff to patient assault with patient injury. In addition, for 3 of 6 sampled patients (Patients #5, #6, and #7) reviewed for restraints, the hospital failed to ensure that patients with restraints were observed every fifteen minutes in accordance with the hospital's guidelines.

Pease see A144 and A175

Based on clinical record reviews, review of hospital surveillance video, review of policies, review of hospital documentation, and interviews for two of two sampled patients (Patients #1 and #11) reviewed for staff to patient abuse, the hospital failed to protect two patients from abuse when P #1 was struck in the face and neck while in 4- point restraints (all Limbs) and P #11 was forced to the ground resulting in a fractured knee. In addition, the hospital failed to include security staff in reeducation following the plan to address the first substantiated abuse. The findings include:

a. Patient #1 presented to the Emergency Department (ED) on 10/7/22 with diagnoses to include oppositional disorder, anxiety, and attention deficit hyperactive disorder.

A physician's order for P #1 dated 10/15/22 at 9:57 PM directed 4-point restraints and Continuous Monitoring sitter.

The ED physician's note dated 10/16/22 at 12:56 AM identified the Physician was called by staff for a crisis regarding Patient #1 on 10/15/22 at 10:00 PM. The note indicated P #1 was medicated and placed in 4- point restraints when the patient became agitated, restless and not directable. The Physician's note indicated the patient complained of a headache after Patient Care Technician (PCT) #1 (assigned as 1:1 sitter) put his knee on Patient #1's neck and proceeded to punch the patient on the left side of the face when Patient #1 spat at PCT #1 who was sitting several feet away. The note identified that the physician evaluated Patient #1 and found petechiae to the anterior lower neck and erythema to the left face.

A review of the Surveillance camera footage with Director of Quality, Manager #1 and Manager #2 on 1/18/22 at 11:27 AM identified the following: At 9:49 am and 15 seconds Patient #1 noted with 4-point restraints in place, lying in bed yelling. At 9:49 and 18 seconds P #1 spat at PCT #1 who was sitting in the doorway to the room. At 9:49 and 21 seconds PCT #1 walked over to P #1 placed his hand over P #1's mouth then placed left knee on the patients' left neck area. PCT #1 was heard yelling "what's your problem", and P #1 was heard yelling, "I can't breathe". At 9:49 & 33 seconds a security guard entered the patient's room along with RN #1. At 9:49 and 39 seconds security guard yelled for PCT to get off patient. At 9:49 and 40 seconds PCT #1 removed himself from P #1. At 9:49 and 43 seconds P #1 sat up in bed with 4-point restraints in place, P#1 was heard yelling, "I can't breathe". At 9:49 and 47 seconds PCT #1 yelled at P #1 "don't you spit on me". At 9:49 and 48 seconds P #1 spat at PCT #1. At 9:49 and 49 seconds PCT #1 hit P #1 in the face, pushed the patient's head to the bed and lunged on P #1. At 9:49 and 50 seconds Security pulled PCT #1 off P #1 and at 9:49 and 50-seconds RN #1 requested staff to leave P #1's room.

An interview with Security Guard #1 on 10/18/22 at 10:58 AM identified that on the day of the incident he was watching the monitor screen and saw PCT #1 on top of P #1. Security Guard #1 indicated that when he entered the patient's room, PCT #1 had his left knee on P #1's neck and hand on the patient's head. Security Guard #1 indicated that he requested that PCT #1 remove himself from the patient and indicated that PCT #1 complied with the request. Security Guard #1 identified PCT #1 struck at patient and hit P #1 in the face in his presence after P #1 spat at PCT #1. Security Guard #1 identified he pulled PCT #1 off P #1 and removed PCT #1 from P #1's room. Security Guard #1 stated that after the incident P #1 became tearful and emotional.

An interview with the Quality Director on 10/18/22 at 10:00 AM identified that after the event of 10/15/22, PCT #1 was removed from Patient #1's bedside, risk management and senior leadership were made aware, Patient #1's family were notified, and the incident was reported to the Police. The Quality Director indicated the Police completed an investigation and PCT #1 was arrested. The Quality Director identified PCT #1 was placed on suspension, his identification badge was deactivated, and he was terminated from the facility on 10/17/22. The Quality Director identified the incident was verbally reported to the state agency and reported to Department of Children and families (DCF).

Review of facility documentation identified that following the incident of 10/15/22 behavioral health staff and Emergency Department Providers were provided with education and support. The Documentation identified that the event was shared in a weekly email of 10/21/22 with all behavioral health staff and identified Crisis Prevention Institute (CPI) principle of rational detachment was discussed to include not taking behaviors of others personally and finding positive outlet for negative energies. The incident was also reviewed in group conversations with topics to include frustration tolerance and the need to take a break or ask for assistance if becoming frustrated with a patient. The document identified that the event was discussed at the ED provider department meeting of October 2022.

Review of the Hospital's Sexual Abuse or Assault Allegation and Employee Investigation Policy directed the Facility is committed to ensuring that all patients remain free from all forms of abuse or assault.

The facility failed to protect the patient from abuse when the patient who was a minor in 4-point restraints was struck in the face and neck by the Patient Care Technician assigned to provide 1:1 supervision.


b. Patient #11 presented to the ED on 11/13/22 with a diagnosis of aggressive behavior.

An Emergency Department (ED) Nursing Note dated 11/14/22 at 5:23 AM identified that at 2:00 AM, Patient #11 went to the door of the Behavioral health unit and when attempted to be redirected, the patient refused to move and postured towards the Security Guard. The note indicated that Patient #11 swung at the guard when the security guard placed his hand on Patient #11's shoulder to guide the patient back to his/her room. The note identified that a code gray (combative patient) was called, and Patient #11 was transferred to bed and placed in a 4- point locking restraint.

The ED Physician note dated 11/14/22 at 6:41 AM identified the provider was contacted at 4:30 AM with a report that Patient #11 was complaining of right sided knee pain. The note indicated the exam was unrevealing of any acute pathology and identified a plan to obtain an X-ray of the knee.

Review of the diagnostic radiology X-ray report dated 11/14/22 at 8:28 AM identified a minimally displaced tibial plateau fracture.

A review of the Computed Tomography (CT) results of Patient #11's knee without contrast dated 11/14/22 at 10:49 AM identified Patient #11 had an extensively comminuted fracture through the entirety of the tibial eminence of the right knee with involvement of a small portion of the articular surface of the medial plateau far anteriorly as well as trabecular fracture of the posterolateral proximal tibial epiphysis without articular surface involvement.

An ED physician note dated 11/14/22 at 9:30 AM identified Patient #11 stated that he/she had been ambulatory until Security placed him/her on the ground causing injury to the knee.

Review of the hospital's surveillance video of the incident of 11/14/22 with Manager #5 (Security Officer) on 11/22/22 at 10:08 AM at 2:04 AM identified that Security Guard #2 asked Patient #11 to go to his/her room. Security Guard #2 then placed 2 hands on Patient #11's shoulder, pushed the patient against the wall and wrestled Patient #11 to the floor and the patient's right knee was observed to hit the floor. Patient #11 was in a prone position with Security Guard #2 lying on top of the patient as Patient #11 stated "my knee hurt".

A review of the Surveillance video footage of the incident lacked evidence that Patient #11 swung at Security Guard #2 at the time that Patient #11 was wrestled to the floor.

In an interview with Manager #5 (Security) on 11/22/22 at 10:25 AM, Manager #5 identified that Security Guard #2 should have called for assistance and should not have taken Patient #11 to the floor unless the security guard or others were in danger of harm. Manager #5 indicated that the security guard's hands should not be put on a patient without clinical guidance. Manager #5 stated that a take-down was not taught in Crisis Prevention Institute (CPI) training.

An interview with the Hospital's Quality Director on 11/22/22 at 10:47 AM identified the Department was informed of the incident on 11/14/22 at 9:30 AM. The Quality Director indicated that concerns were raised, the leadership team met, reviewed the incident, and determined the action of the security guard was inappropriate. The Director identified the security guard was placed on suspension, the police were called, and the patient's family was made aware of the incident. The Director stated the decision was made to terminate the security guard.

An interview with Manager #1 (Behavioral Health) on 11/22/22 at 11:55 AM identified that subsequent to the first incident of staff to patient abuse (10/15/22), the incident was discussed with staff within the Behavioral Health unit through individual and group conversations, emails, in safety huddles, and team meetings. Manager #1 indicated that discussions included Crisis Intervention Institute training (CPI) principle of staying calm, maintaining professionalism, not taking the behaviors of others personally and finding positive outlets for negative energy absorbed during a crisis.

Review of the email sent out to staff with Manager #1 on 11/22/22 at 11:55 AM identified that recipients of the email did not include the security staff.

An interview with RN #3 on 11/22/22 at 2:05 PM identified that at the time of the incident Patient #11 was restless and anxious about remaining in the hospital overnight. RN #3 identified that Patient #11 was asked to return to his/her room multiple times. RN #3 stated she heard the commotion when Patient #11 was brought to the floor and indicated she called a code Gray. RN #3 identified that she performed an assessment of Patient #11, but the patient did not voice any complaints of pain or discomforts. RN #3 identified that later in the shift, Patient #11 voiced a complaint of right knee pain. RN #3 stated the Physician Assistant was notified, and the patient was medicated for pain.

In an interview with Supervisor #1 (Security) on 11/22/22 at 1:55 PM, Supervisor #1 identified that he was made aware of the prior incident (10/15/22) of staff to patient abuse through other staff members. Supervisor #1 indicated that the security guards were not involved and stated that in terms of corrective action or education of the security staff, nothing was done.

Review of the Hospital's On-the-Job Training guide for Security officers directed physical holds should only be applied at the guidance of clinical staff. The Training Guide further directed that holds occur when clinical staff need to provide medical care that the patient is not cooperating with, but mechanical restraints are appropriate.

The Hospital's Bill of Rights and Responsibilities directed that each patient has the right to be free from all forms of abuse or harassment, including seclusion, or restraints that are not medically indicated or are used as a means of coercion, discipline, convenience, or staff retaliation.

Review of the Hospital's Sexual Abuse or Assault Allegation and Employee Investigation Policy directed the Facility is committed to ensuring that all patients remain free from all forms of abuse or assault.

The Facility failed to reeducate all staff providing care and supervision to behavioral patients following a substantiated staff to patient abuse with injury, resulting in a subsequent staff to patient abuse with injury.

Based on clinical record reviews, review of hospital documentation, interviews, and record documentation guidelines review for 3 of 6 sampled patients (Patients #5, #6, and #7) reviewed for restraints, the hospital failed to ensure that patients with restraints were observed every fifteen minutes in accordance with the hospital's guidelines. The findings include:

a. Patient #5 was admitted to the Hospital on 10/13/22 with a chief complaint of suicidal attempt. A physician's order dated 10/13/22 at 12:59 AM directed to apply a 4-point locking limb restraint and a constant monitoring sitter.

The Physician's Evaluation Restraint/Seclusion document dated 10/13/22 at 1:00 AM identified P #5 was agitated and irritable, identified P #5 failed to respond to less restrictive alternatives, and identified P #5 was in need of restraints to prevent injury to others.

The restraint episode activity documentation identified that Patient #5's restraints were discontinued on 10/13/22 at 3:54 AM (total time in restraints-2 hours 55 minutes). The clinical record lacked documentation that the patient's behaviors and activities were observed every fifteen minutes in accordance with facility guidelines.

Interview with the Hospital's Director of Quality on 11/4/22 at 4:16 PM identified that the hospital was unable to provide documentation of the patient's behaviors and activities during the period of 12:59 AM to 3:54 AM.

Review of the hospital's Attendant Observation Record documentation guidelines directed a patient who required a behavioral attendant will have observed behaviors documented every 15 minutes.


b. Patient #6 was admitted to the Hospital on 8/13/22 with suicidality. The nurse's note dated 8/13/22 at 11:32 PM indicated that Patient #6 appeared intoxicated, was restless, delusional, agitated, yelling, screaming, spitting and aggressive.

The physician's order dated 8/13/22 at 10:45 PM directed to apply a 4-point locking limb restraint and a Behavioral attendant.

The Physician's Evaluation Restraint/Seclusion document dated 8/13/22 at 10:44 PM identified P #6 was agitated, and irritable, failed to respond to less restrictive alternatives, and indicated P#6 was in need of restraints to prevent injury to self and others.


Review of the clinical record identified that Patient #6 was placed in 4-point restraints on 8/13/22 at 9:45 PM. The restraint Episode Activity documentation identified that Patient #6's restraints were discontinued on 8/13/22 at 11:04 PM (total time in restraints 1 hour and 19 minutes). The clinical record lacked documentation Patient #6's behaviors and activities were observed every fifteen minutes in accordance with facility guidelines.

Interview with the Hospital's Director of quality on 11/4/22 at 4:16 PM identified that the hospital was unable to provide documentation of the patient's behaviors and activities of 9:45 PM to 11:04 PM on 8/13/22 when patient was in restraints.


c. Patient #7 was admitted to the hospital on 9/30/22 after being brought in by emergency medical service (EMS) at 12:17 PM already in 4-point restraint. Patient #7's diagnoses included intellectual disability, voiding on floor of home and positive urine toxicology.

A nursing note entered on 9/30/22 at 1:28 PM identified that Patient #7 arrived via EMS with 4-point restraint in place yelling, attempting to bite the restraints, and was unable to be redirected. The nurse's note identified Haldol and Ativan Intramuscularly were administered per physician's orders.

The Initial Evaluation/restraint seclusion document dated 9/30/22 at 3:25 PM identified that Patient #7 was agitated and angry and failed to respond to less restrictive alternatives and that the patient was in need of restraints to prevent injury to others.

The Physician's order dated 9/30/22 at 3:25 PM directed to apply 4-point locking limb restraint and Behavioral attendant.

The restraint episode activity documentation identified that Patient #7's restraints were discontinued on 9/30/22 at 3:57 PM (total time in restraints-2 hours 29 minutes). The clinical record failed to identify the patient's behaviors and activities were observed every fifteen minutes in accordance with facility guidelines.

Interview with the Hospital's Director of quality on 11/4/22 at 4:16 PM identified the hospital was unable to provide documentation of the patient's behaviors and activities during the period 9/30/22 12:17 PM to 3:57 PM (restraints discontinued).

An interview with Quality Manager #3 and Psychiatry Manager #4 on 11/2/22 at 1:45 PM indicated it was the practice and expectation that restraints are discontinued as soon as the patient exhibits no behavioral concerns.

Interview with the Hospital's Director of Quality on 11/4/22 at 4:16 PM indicated that the hospital was unable to locate documentation of attendant observation records for Patient #5, 6, and 7. The Director identified this as a system error and stated the documents may have been misplaced or shredded before being uploaded to the patients' clinical records.

Review of the Hospital's Attendant Observation Record Documentation Guidelines directed a patient who required a behavioral attendant will have observed behaviors documented every 15 minutes.