HospitalInspections.org

Based on observation, medical record review, staff interview, review of video surveillance, and review of facility documentation, it was determined that the facility failed to ensure the protection and promotion of patient rights.

Findings include:

1. The facility failed to ensure that staff that witnessed patient abuse failed to report the abuse. (Refer Tag A-0145)

2. The facility failed to ensure that when a patient reported abuse to a provider, the provider failed to report the abuse. (Refer Tag A-0145)

3. The facility failed to ensure patients are free from abuse, by ensuring implementation of facility policies and procedures, and by fully implementing the facility action plan following an allegation of staff to patient abuse. (Refer Tag A-0145)

Based on observation, review of one of one Medical Record (Patient (P) 1) of a patient alleging abuse by a staff member, staff interview, and review of facility documents, it was determined that the facility failed to ensure patients are free from abuse, by ensuring implementation of facility policies and procedures, and by fully implementing the facility action plan following an allegation of staff to patient abuse.

Findings include:

Facility policy titled, "Reportable Incidents", revised 9/2021 stated, "... Electronic Incident Report An Electronic Incident Report is to be completed for all incidents involving patients, medication variances, visitors, staff, safety concerns, and employee health or safety issues. The staff member with the most knowledge of the event has the responsibility to complete the incident report. If the incident occurs during business hours Monday through Friday, the person in charge will notify the Unit Director or Designee, and the Attending LIP [Licensed Independent Practitioner]. Besides completing an electronic incident report, a progress note should be written in the medical record by the staff member with knowledge of the incident ..."

Facility policy titled, "Guidelines for Cooperation and Discipline", revised 10/2018 stated, "... As a condition of employment... all team members accept responsibility for adhering to the particular rules and guidelines of their individual position and department/unit as well as to the general rules and standards of behavior that apply to all team members throughout the organization. Leaders are charged with monitoring team member performances and adherences to applicable guidelines ... LEVEL 1 Infractions ... G. Failure to perform duties as assigned or at the expected level of competency H. Failure to follow the [Health Care System] standards of behavior and conduct I. Failure to follow [Health Care System] policy resulting in non-serious consequences ... M. Creating an unsafe or unsanitary condition or contributing to such conditions ..."

On 9/14/23 at 9:58 AM, the video surveillance footage of an alleged incident of abuse from 9/5/23 that occurred from approximately 4:51 PM to 5:25 PM, was reviewed in the presence of Staff (S) 1, Vice President of Patient Services, and S3, Security Manager. On 9/5/23 at 4:52:42 PM, P1 was observed being brought into a room in the quiet area of the General Adult Unit (GAU). P1 was placed in four-point restraints and then covered with a restraining blanket. The video footage showed S11, a Mental Health Technician (MHT), pouring water on the face of P1, at three different times (5:03:46 PM, 5:04:07 PM, and 5:04:33 PM), while the patient was in four-point restraints in the Quiet Area of the GAU. P1 appeared to be talking to S11, and then was observed spitting in the direction of S11. S11 then placed his left hand to grip the patient's chin, while his left forearm rested on the patient's chest, and S11 leaned in close to the patient from approximately 5:04:36 PM to 5:04:50 PM, at which point he then released his grip, backed away from P1 and left the room. S11 was observed returning to the room at 5:22:07 PM with another staff member to check the patient's restraints. The second staff member left and at 5:23:29 PM, S11 picked up a sheet from the corner of the room and approached P1. S11 and P1 were observed speaking with each other when P1 started spitting in the direction of S11. At 5:24:04 PM, S11 then took the sheet and forcibly placed it over P1's face, covering the patient's nose and mouth. At 5:24:10 PM, three other staff members, S7, a Registered Nurse (RN), S8, a MHT, and S12, a MHT who was orienting to the unit, had entered the room as S11 was covering the face of P1 with the sheet. At 5:24:18 PM, S8 was observed moving S11's hand and the sheet away from P1's face and replacing it with a mask to cover P1's nose and mouth. All of the staff members left the room at 5:24:31 PM. The staff members in the video were identified by S5, Nurse Manager of the GAU on 9/14/23 at 10:28 AM. A review of the medical record of P1 identified that a progress note had not been made by S7 after the incident had occurred.

Facility policy, titled "Patient Safety Plan", stated, " ... Staff is encouraged to report patient safety concerns through the various reporting mechanisms established to capture such concerns including directly to the Patient Safety Officer, the Quality and Safety (Patient Safety) committee, the Risk Manager, the Corporate Compliance Hotline, and through incident reports. These reporting mechanisms provide confidential and anonymous reporting opportunities ... [Facility name] does not support punitive action for any kind of reporting of errors or quality concerns, though it will take immediate action, as indicated, to protect the safety of all patients, staff, and visitors ..."

S5 stated that she had first heard of the incident that occurred on 9/5/23 when P1 filed a verbal complaint with her (S5) on 9/7/23. Facility administration was alerted to the incident on the evening of 9/7/23. S5 stated that a unit re-education plan was put in place starting on 9/8/23. The re-education included all staff members on the unit, to review seven policies: "High Reliability Universal Skills"; "Restraints"; "Handle With Care"; "Standards of Professional Practice"; "Physical Intervention"; "Standards of Behavior"; and "[Health Care System] Code of Conduct." On 9/14/23, S5 provided a copy of the education materials, and the sign in sheet of staff members that were to have completed the training. S7 and S8 had completed the training. As of 9/14/23, 12 staff members out of 51 had not yet completed the training. Eight of the 12 staff members had worked between 9/8/23 and 9/14/23 without having completed the re-education. On 9/14/23, S5 provided an email to the surveyors, that was sent to the twelve staff members that had not yet received the education, indicating that they are not allowed to work their next shift until the education is completed.

On 9/14/23 at 1:15 PM, S5 confirmed that S7 and S8 should have reported the incident when it had occurred on 9/5/23 and that S7 and S8 failed to report the incident per facility policy. The daily nursing assignment sheets from 9/4/23 to 9/14/23 for all shifts for the GAU were reviewed. S11 was noted to have finished his shift on 9/5/23 at 7:00 PM. S7 and S8 failing to report abuse places patients at risk for further abuse from S11. S5 stated that she was not notified by her staff regarding the incident. S5 stated that she and S3 reviewed the video footage immediately upon hearing the accusation on 9/7/23. S5 stated that per facility protocol, the incident was escalated for further investigation, S11 was suspended pending a completed investigation, and facility administration was notified the evening of 9/7/23. S1 and S5 confirmed that incident reports had not been filed by S7, S8, S11, or S12. A review of the facility incident report that was entered by S5 on 9/8/23, noted that there no witnesses identified to the incident. S5 stated that she had spoken with S7, S8, and S12, but S5 was unable to provide documented evidence of those interviews.

Continued review of the medical record noted a physician addended note written as part of the original face to face note on 9/5/23 at 17:44 (5:44 PM). S10, the on-call Psychologist, stated, "... [Patient] was seen in QA [Quiet Area] while [he]/she is on restraints and was making accusations towards staff ..." Upon further review, the medical record lacked information from the physician regarding the accusations. An interview was conducted with S10 in the presence of S1 on 9/14/23 at 2:50 PM. Upon interview with S10 on 9/14/23 at 2:51 PM, S10 stated that he could not expound on the accusations, and that he was just the on-call physician. S10 stated that if there were accusations then he would have reported them to the charge nurse on duty, but would not have necessarily provided that information to another physician in a hand off report. S10 was unable to provide evidence that P1's accusations were reported to the charge nurse on 9/5/23. At 3:13 PM, S1 confirmed that S10 should have reported the accusations to the Charge RN on duty, and should have completed an incident report. S1 stated that based on S10's interview, the providers at the facility should have be included in the re-education.

The personnel education files were requested and reviewed for S7, S8, S10, S11, and S12. The education for patient rights and abuse were found to be completed and up to date for the year 2023.