HospitalInspections.org

Based on interview, record review, and review of the facility's policies, Report of Unusual Incident (RUI) and video footage, it was determined the facility failed to ensure Patient Rights were protected for one (1) of ten (10) sampled patients (Patient #1). Patient #1 experienced a behavioral episode on 02/23/24 at 11:30 AM, in which Patient #1 struck a staff member, Mental Health Associate (MHA) #1 who responded by kicking the patient in the chest.

The findings include:

Review of the facility's policy titled, "General Hospital Policies, Section 5, Ethics and Patient Rights Policies", reviewed August 2013, revealed staff were to treat patients with respect and dignity in a caring conscientious manner. Continued review of the policy revealed the facility was "committed" to providing ethical care which ensured patients and their families dignity, respect...and preservation of Patient's Rights.

Review of Patient #1's medical record revealed the facility admitted the patient on 02/19/14, from another hospital where he/she had been suffering auditory hallucinations commanding him/her to kill himself/herself. Continued review of the record revealed Patient #1 had diagnoses which included Impulse Control Disorder Not Otherwise Specified (NOS), Adjustment Disorder Mixed with Disturbance of Conduct and Emotion, and Psychotic Disorder NOS. Further review revealed Patient #1 was discharged from the facility on 02/24/14.

Review of the facility's document titled, "Report of Unusual Incident" (RUI) dated 02/23/14, revealed at 11:30 AM on 02/23/14, Patient #1 had been threatening staff, throwing items at staff, and spitting at staff. Continued review revealed Patient #1 attempted to go behind the nurse's station "towards" MHA #3. Review of the document revealed Patient #1 became "combative" and staff placed him/her in a physical hold and eventually in restraints. Further review of the RUI revealed "during the struggle" Patient #1 punched MHA #1 in the groin area; and "in response" MHA #1 kicked Patient #1 in the chest area.

Review of video footage for 02/23/14 at 11:30 AM, taken at the time of the incident, revealed Patient #1 was observed to lunge across the nurse's station in an attempt to reach a female staff member, MHA #3; then used the nurse's station as support to lunge around in another attempt to reach MHA #3. MHA #1 was observed to intervene and placed himself between Patient #1 and MHA #3; at which point Patient #1 grabbed MHA #1 and a struggle ensued which ended with both on the floor beside the nurse's station. Continued observation of the video footage revealed at that point other staff were observed to come to assist; and when other staff held Patient #1, MHA #1 stood and attempted to move away. Observation revealed Patient #1 to then punch MHA #1 in the groin area; and the MHA #1 was observed to kick down towards Patient #1's chest area, before he moved away and clutched his groin area.

Interview with Registered Nurse (RN) #1 on 02/26/14 at 12:41 PM, revealed Patient #1 had been redirected by staff more than once on the morning of 02/23/14, for following MHA #3 around in his/her wheelchair and saying inappropriate things to her. RN #1 revealed Patient #1 had used racial slurs, as well as, insulting MHA #3's for being a young single mother. RN #1 stated when Patient #1 stood up from his/her wheelchair and lunged around the nurse's station, MHA #1 had stepped out of the conference room and stood in front of Patient #1. RN #1 indicated there had been a verbal exchange between MHA #1 and Patient #1, during which Patient #1 continued to use racial slurs towards MHA #1 and the MHA used profanity towards Patient #1. According to RN #1, he had went behind Patient #1, the patient lunged towards MHA #1, and he and MHA #1 "directed" Patient #1 to the ground after this. The RN stated, during the struggle, Patient #1 continued with "yelling stuff" including racial slurs; and MHA #1 used profanity towards Patient #1. He stated he thought MHA #1 was "angry" and didn't think the MHA was "being professional". RN #1 revealed he had not seen Patient #1 hit MHA #1, and had not seen MHA #1 "kick" Patient #1. He stated it was "hectic" and he did recall MHA #1 stated the patient had kicked him in the groin area. Additionally, he stated he had heard Patient #1 complain MHA #1 had "kicked" him/her in the chest.

Patient #1 had been discharged from the facility on 02/24/14, and had no telephone number listed as to where he/she could have been contacted for interview. Therefore, an interview with Patient #1 could not be conducted.

Interview with MHA #3 on 02/26/14 at 4:11 PM, revealed she had been making her rounds on the morning of 02/23/14, and Patient #1 had been following her around making derogatory comments towards her. She stated despite redirection on the morning of 02/23/14, Patient #1 lunged across the nurse's station in an attempt to strike her. MHA #3 stated Patient #1 was spitting on her, cursing her and coming around the nurse's station, when MHA #1 stepped out of the conference room and intervened. She stated she had not seen exactly what happened; however saw Patient #1 on the ground on his/her back with staff around. MHA #3 stated Patient #1 had been spitting and attempted to "grab" and hit staff. She indicated Patient #1 had been cursing, calling her and MHA #1 "niggers" and threatened to sue the facility. According to MHA #3, she saw Licensed Practical Nurse (LPN) #1's hair pulled and saw her get "kneed" in the stomach; but had not seen any other physical violence. MHA #3 revealed she had seen MHA #1 go back behind the nurse's station holding himself; and heard him say something about having been hit or kicked.

Interview with LPN #1 on 02/26/14 at 1:07 PM, revealed she had heard of Patient #1 "harassing" MHA #3 on the morning of 02/23/14. She stated MHA #1 was in the conference room with her when they heard a "commotion" outside the door. LPN #1 stated MHA #1 left the room and she followed shortly after him. According to LPN #1, Patient #1 was out of his/her wheelchair and coming around the nurse's station, she heard "yelling" and observed staff with Patient #1 on the floor. She stated MHA #1 came back behind the nurse's station stating Patient #1 had "kicked" him in the groin area. LPN #1 stated she had not seen MHA #1 do anything inappropriate however.

Review of RN #2's written statement, obtained after the incident on 02/23/14 at 1:45 PM, revealed Patient #1 had been assessed shortly after 12:00 PM; and there had been no redness or bruising noted to the patient's chest area. Further review of RN #2's written statement revealed Patient #1 had denied shortness of breath or other complaints at the time of her assessment.

Interview with the Director of Risk Management on 02/26/14 at 4:34 PM, revealed MHA #1 had failed to control his behaviors and had acted inappropriately on 02/23/14 at the time of the incident. According to the Director staff were not allowed to touch patients inappropriately, as MHA #1 had done during the incident on 02/23/14. She stated all facility staff had been trained in Crisis Prevention and Intervention (CPI); and the proper way to respond to patient's experiencing violent behaviors. The Director of Risk Management stated MHA #1 had not followed CPI and what he had been taught when he struck back at Patient #1 on 02/23/14 during the incident. She indicated MHA #1 was to be terminated related to the incident.

Review of MHA #1's employee file revealed he had completed CPI training on 07/09/13.

Attempts were made to telephone MHA #1, on 02/26/14, however were unsuccessful.