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Based on document review, observation, and interview the facility failed to keep patients free from abuse or harassment for 2 of 10 medical records reviewed. (P1 & P2) See tag 0145

The cumulative effect of this systemic problem resulted in the facility's inability to ensure that Patient Rights were promoted.

Based on document review, observation, and interview the facility failed to keep patients free from abuse or harassment for 2 of 10 medical records reviewed. (P1 & P2)

Findings Include:

1. The facility policy titled, "Suspected Child, Adult, Disabled Person or Elderly Abuse/Neglect/Exploitation", PolicyStat ID 14414852, last revised 09/2023, indicated employees shall not subject a patient to any sort of abuse, neglect, or exploitation.

2. The facility policy titled, "Patient Bill of Rights", PolicyStat ID 14373415, last revised 10/2023, indicated patient's have the right to be free from physical and or emotional abuse by any member of the staff.

3. P2's medical record was reviewed and indicated Seclusion & Restraint documentation dated 9/11/23 for P2 indicated the restraint started at 8:33 pm and ended 8:35 pm. The patient was pacing the unit, yelling at staff and peers, threw a large coffee carafe at a PCA hitting him/her in the lower back, patient stuffed napkins down his/her throat, patient elbowed a plexiglass shadowbox dislodging the glass, attempted to bite PCA staff member.

4. Human Resources investigation documentation dated 9/14/23 by A3; On 9/14/23 A3 (Senior Human Resources Business Partner) spoke with PCA 1(Patient Care Assistant) regarding the incident between him/her and P1. PCA 1 stated that P1 attacked him/her without reason. During the altercation the staff members glasses were broken causing cuts on his/her face. PCA 1 reported he/she and P1 fell during the altercation causing the staff member an injury to his/her right leg.

5. Human Resources investigation documentation dated 9/15/23 indicated and A3 reviewed the 9/11/23 video footage. This video footage confirmed that PCA 1 held P2 against the wall with his/her hand on the patient's neck an additionally placed his/her gloved hand over the patient's mouth and nose for approximately 42 seconds.

6. Observation of video surveillance for incident on 9/14/23, between P1 and PCA 1, conducted on 2/9/24 at approximately 10:00 am with A2 (Director of Quality) confirmed P1 approached PCA 1 in an attempt to harm her and at the same time PCA 10 (Patient Care Assistant) intervened placing an arm between the patient and PCA 1. Video footage shows that PCA 1 did not back away or use appropriate CPI (Crisis Prevention Institute) training. The patient and the staff member in what appeared to be an active fight. PCA 10 continued to try and stop the altercation. The video showed PCA 1 putting his/her arm around P1's neck and in doing so P1, PCA 1 and PCA 10 all fell to the ground. Once PCA 11 (Patient Care Assistant) arrived along with other staff members, P1 and PCA 1 were successfully separated.

7. Observation of video surveillance for incident on 9/11/23, between P2 and PCA 1, was conducted on 2/9/24 at approximately 1:00 pm with A2 (Director of Quality) confirmed that PCA 1 held P2 against the wall with his/her hand on the patient's neck an additionally placed his/her gloved hand over the patient's mouth and nose for approximately 42 seconds. PCA 1's actions were inappropriate and did not meet CPI training

8. In interview on 2/9/24 at approximately 11:20 am with PCA 10 (Patient Care Assistant) indicated on 9/14/23 while in the cafeteria he/she told P1 to place his/her cup in the window, P1 was upset over the length of meal time (30 minutes), P1 did not say anything after that but charged at PCA 1, he/she put an arm between the patient and the staff member, the patient swung at the staff member over his/her arm, he/she was unsure when PCA 1 started hitting back, the patient and staff member had each other by the hair at one point then they went down to the floor, PCA 10 tried to break the two apart, PCA 11 came in and broke the two apart. PCA 10 indicated he/she hadn't seen PCA 1 be aggressive prior to this altercation.

9. In interview on 2/9/24 at approximately 12:37 pm with PCA 11 (Patient Care Assistant) indicated he/she was the first to respond to the altercation in the cafeteria on 9/14/23, PCA 1 had the patient by the hair and had to be told numerous times to let the patient go, felt PCA 1 was aggressive/overreacted during codes using too much force, and would rarely use deescalating training before doing a physical hold, PCA 1's mood affected his/her care and was known to work a lot of hours, and felt the event from 9/14/23 was a fight because PCA 1 could have backed down/away and did not.

10. In interview on 2/12/24 at approximately 2:10 pm with PCA 3 (Patient Care Assistant) indicated during the hold/restraint on 9/11/23 with P2, PCA 1 had his/her hand on the patient's face, did not do the incident report but did report the hold and report the details of the hold to N1 at the end of the shift

Based on document review and interview, the facility failed to ensure an incident report was filed by the end of shift for 2 of 10 patients. (P1 & P2)

Findings include:

1. The facility policy titled, "Incident Report Protocol & Patient Safety Events", PolicyStat ID 14854330, last revised 01/2024, indicated incident reports are to be filled out for any patient safety incident. The incident Report should be filled out as soon as practicable after the incident has occurred. Optimally, Incident Reports must be completed at the time of the event and appropriate notification of the supervisor immediately, but no later than the end of shift.

2. On 9/12/23 at 7:57 am A2 (Quality Director) created an incident report for a restraint/hold on P2 that occurred on 9/11/23. There was no incident report filed on 9/14/23 for P1 grabbing another patient's finger and bending it backwards.

3. In interview on 2/12/24 at approximately 2:30 pm with A2 (Quality Director) confirmed the incident report for the 9/11/23 event with P2 was filed on 9/12/23 at 7:57 am by him/her and not by staff whom took part in or witnessed the incident and an incident report was not filed for incident involving P1 grabbing a peers finger backwards and should have been.

Based on document reviewed and interview, the facility failed to ensure patient safety when employing 1 of 1 agency staff. (PCA 1)

Findings include:

1. The facility policy titled, "Background and Credit Check Policy", PolicyStat ID 12583330, last revised 11/2022, indicated when evaluating a criminal record, Human Resources will consider: (1) the nature and gravity of the offense(s); (2) the time that has passed since the offense(s) and/or completion of the sentence(s); and (3) the nature of the job held or sought. Factors that will be considered include:
The facts and circumstances surrounding the offense or conduct;
The number of offenses for which the candidate was convicted;
Evidence that the candidate performed the same type of work, post-conviction, with the same or a different employer, with no known incidents of criminal conduct;
The length and consistency of employment history before and after the offense;
Rehabilitation efforts(e.g., education and training; certificate of good conduct);
Employment or character references and other information regarding fitness for the particular position;


2. Review of personnel file for PCA 1 (Patient Care Assistant) indicated the following:
PCA 1 held a suspended Indiana Registered Nurse License at the time of hire to F1(Psychiatric Hospital); license was suspended by B3 (Licensing Agency) on 6/21/16 for knowingly violating a rule regulating the nursing profession. On 3/13/2019 B3 concluded that he/she failed to comply with the terms of the conditions set on 10/19/2016 and his/her nursing license was placed on INDEFINITE SUSPENSION until he/she completed AT LEAST SIX (6) MONTHS OF FULL, CONTINUOUS AND COMPLETE COMPLIANCE with an ISNAP (Recovery Program) RMA(Recovery Monitoring Agreement) and followed all therapy recommendations for his/her substance abuse and/or mental health evaluation, which included individual therapy.

3. Incident of patient abuse occurred between PCA 1 and P1 on 9/14/23.

4. In interview on 2/12/24 at approximately 1:10 pm with A3 (Senior Human Resource Business Partner) indicated he/she verified that initial hiring documentation had information related to PCA 1's suspended nursing license. PCA 1's court documents related to his/her suspended license were added to the staff members file during a monthly audit much later after hire and cannot remember the month they were added. A3 confirmed that PCA 1's termination was not reported to B3.