HospitalInspections.org

Based on interview and record review it was determined the hospital failed to ensure that 1 of 10 sampled patients (Patient 5) was free from physical abuse by staff.

Findings include:

During the survey it was revealed by Witness 1 (CNO/COO) that the hospital had identified and reported an incident of physical abuse by a staff member to Patient 5. The incident reportedly had occurred in the hospital on 10/16/13 and had been reported to the Division and other applicable agencies on 11/20/13.

In interview on 12/10/13 at 11:45 am Witness 1 stated that on 10/16/13 at approximately 1:00 pm Employee 2 (Security Manager) had been observed "striking, pushing and spanking" Patient 5. The incident reportedly occurred in the Emergency Department Crisis Unit, and had been witnessed by Employee 5 (Security Officer), Employee 9 (RN) and Employee 12 (Security Officer). During the interview Witness 1 provided written documentation from Employees 5, 9 and 12 that verified the description of the event.

During the survey the sequence of events and time delay before reporting of the incident was reviewed. Reportedly the incident was observed by Employees 5, 9 and 12 on 10/16/13. On 10/26/13 Employee 9 (RN) first reported the incident to his/her manager, Employee 11. The ten day delay in the initial reporting of the event by Employee 9 (RN) is noted.

Witness 1 stated that s/he first became aware of the incident on 10/27/13, and immediately initiated an internal investigation. That investigation had been documented in hospital records, and concluded that the incident did occur as described. Hospital records reflect that the incident was reported to the Health Division, the Civil Commitment Coordinator: Additions and Mental Health Division, and Children Services Division on 11/20/13.

Witness 1 reiterated that the hospital had self-reported the incident, but acknowledged that the incident of physical abuse of Patient 5 had occurred on 10/16/13 as described by Employees 5, 9 and 12.

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Based on interview and record review it was determined that hospital nursing staff (Employee 9) failed to supervise the nursing care for 1 of 10 sampled patient's (Patient 5).

Findings include:

During the survey it was revealed by Witness 1 (CNO/COO) that the hospital had identified and reported an incident of physical abuse by a staff member to Patient 5. In interview on 12/10/13 at 11:45 am Witness 1 stated that on 10/16/13 at approximately 1:00 pm Employee 2 (Security Manager) had been observed "striking, pushing and spanking" Patient 5.

The incident reportedly occurred in the Emergency Department Crisis Unit, and had been witnessed by several employees including Employee 9 (RN). According to hospital staffing records Employee 9 had been assigned to provide nursing care to Patient 5.

During the survey the sequence of events and time delay before reporting of the incident was reviewed. Reportedly the incident was observed by several staff, including Employee 9, on 10/16/13 at approximately 1:00 pm. Employee 9 (RN) first reported the incident to his/her manager, Employee 11, on 10/26/13. The ten day delay in the initial reporting of the event by Employee 9 (RN) is noted, and is not in compliance with hospital policy "Reporting of Incidents", or with State law.

In interview with Witness 1 on 11/20/13 Employee 9 reported that s/he "relies heavily on security to help him/her in the (Crisis Unit) rooms and was concerned that they would not respond timely if s/he reported this"... incident. After several days of reflection Employee 9 concluded that the incident "had to be reported," and contacted his/her manager on 10/26/13.