HospitalInspections.org

Based on interview and record review the facility failed to thoroughly investigate a staff-to-patient allegation of abuse and notify the appropriate agencies in accordance with State laws for two of two identified incidences of potential abuse.

Findings:

1. On 5/25/2022 at 9:30 am, the employee file of Staff EE, a Behavioral Health Technician, was reviewed with the Chief Nursing Officer (CNO). The file included an email document written by a facility staff reporting an allegation of verbal abuse against a Staff EE dated 10/8/2021. The document indicated "This morning, 10/08/2021, when I went to Unit A to see patients, I witnessed ...I heard [Staff EE] yell at a patient ...what the [expletive] are you doing? You better not be peeing on the door. I will put my [expletive] hands on you ..." The document identified the involved patient (Patient #11) and the name of another patient who found the incident to be "upsetting." The CNO stated, "I told my staff to send an email about the incident when she reported it."

Staff EE's employee file also included a "Progressive Discipline Document" signed and dated by the CNO on 10/28/2021. The document indicated, "On 10/08/2021 [Staff EE] was overheard using inappropriate language directed at a patient. To [ Staff EE]'s own admission he informed this writer that he had asked a patient "what the [expletive] are you doing?" Using foul language or shouting at a patient is considered verbal abuse. The document further indicated "Due to this incident along with your failure to maintain the standards/tardiness you are being issued a final warning."

On 5/25/2022 at 9:37 am, The Director of Risk Management (DRM) was interviewed. The DRM stated she checked her log and there were no reported staff-to-patient allegations from January 2021 up until the time of the survey. The DRM stated she was not aware of any staff-to-patient allegations of abuse from January 2021 up until the time of the survey. The employee file of Staff EE was reviewed with the DRM. The DRM stated she was not aware of the case, "I did not conduct an investigation about it, there's no incident report about it." The DRM stated, "I would have called DHS and reported it."

On 5/25/2022 at 10:34 am the medical record of Patient 11 was reviewed with the CNO. The CNO confirmed there was no documentary evidence in Patient 11's medical record of the incident nor assessment or follow-up from the facility in response to the verbal abuse the patient received from Staff EE.

On 5/25/2022 at 1:58 pm, the employee file of Staff EE was reviewed with Human Resources Director (HRD). The HRD stated she was unable to find any "investigatory notes" related to the allegation of verbal abuse against Staff EE. The HRD stated the final written warning could be considered as the substantiation document. The HRD stated "Usually I am involved in investigations regarding staff allegations of abuse." The HRD stated there is no documentary evidence of re-training or of a corrective plan in response to the verbal abuse Staff EE admitted to on the final written warning. The HDR stated Staff EE's last abuse training prior to the incident was on June 8, 2021. The HRD stated Staff EE was terminated on 2/25/2022.

On 5/26/2022 at 12:00 pm, the CNO was interviewed. The CNO stated the Risk Manager is responsible for following up with patients involved in staff-to-patient allegation of abuse. The CNO stated she conducts the nursing staff interviews.

Review of the facility policy and procedure, "Abuse and Neglect" issue date 4/2020, indicated: " ...Staff to Patient Abuse or Neglect a. The staff member shall be notified of the allegation and suspended from duty, pending results of the investigation ...c. The CEO and the Director of Risk Management will be notified immediately ...Documentation a. The Medical Record shall include documentation of examinations, treatment given, any referrals made to other care providers and to community agencies ...Investigation a. Reports of Abuse or Neglect which occur while the patient is hospitalized will be thoroughly investigated by the Risk Manager or other staff assigned by the Chief Executive Officer. b. Interviews related to the investigation will be completed by the Risk Manager, Human Resources Director, or the Patient Advocate, as assigned by the Chief Executive Officer ...9. Follow-Up b. If the allegation of abuse is substantiated through a thorough and complete investigation, the staff member shall be terminated and reported to the appropriate licensing board, and regulatory agencies as applicable.

Review of the nursing policy and procedure, NS-1003 "Recognizing & Reporting Suspected Abuse/Neglect/Exploitation of a Vulnerable Adult" revised 07/2021 indicated: " ...All allegations, observations or suspected cases of abuse, neglect or exploitation that occur in the facility will be investigated ...Employees will notify their supervisors immediately of the suspected allegations or witnessed abused. e. The supervisor of the employee will also notify the CEO, Administrator on call, and the Risk Manager or designee. f. All cases of suspected abuse/neglect against a vulnerable adult must be reported to the Florida Abuse Registry Hotline ...v. All cases of suspected abuse/neglect will also be immediately reported to law enforcement ..."

2. Review of the grievance and complaint log, dated 4/22/22, revealed a complaint was reported by 4 patients. The category designated to the complaint was "abuse-verbal". The log indicated the complaint was assigned to the DON (director of nursing). The log also indicated the complaint was unsubstantiated. Four patients signed one complaint regarding a nurse being verbally inappropriate. DON (Director of Nursing) spoke with nurse.

Review of the Compliment/Suggestion Form, dated 4/22/22, reflected the following:
Nurse BB, RN (registered nurse) made several inappropriate and aggressive comments toward several individuals on the unit. These comments include but are not limited to "Get used to it, you owe me now." When one client asked if an elderly client was ok (because the elderly client vomited earlier) the RN barked "Are you a tech?" The client replied I was just asking if he was ok. Then he said, "worry about yourself that's why you're here." The client just walked away. Several clients got in arguments about simple terms with this man. Made a whopper of a mistake and gave the patient a wrong medication and accused other nurses of butting in. Failed to provide medical information in time of crisis. Used phrase "I am not a doctor" when a client asked if it was ok to take Advil with a concussion.
There were four patients' names who witnessed the allegations.
A note at the bottom of the form indicated a nurse discussed the RN's behavior with supervisor.
An additional note reflected the information was forwarded to the DON. "The RN has quit his position this week and will not be returning. Unable to move forward with anything." Resolved 4/27/22. The initials of the patient advocate were next to the date.
Review of the email body attached to the form, also signed with the patient advocate's initials, reflected a note that indicated "info presented in Flash meeting for discussion". There was no further information provided indicating the patients were interviewed or assessed, or that statements were taken from the any staff members or other patients, or any other follow up (investigation) had been completed.

Review of the email content, from the patient advocate to the risk manager, dated 4/26/22, (four days later) revealed the following:
Multiple patients complained about [Nurse BB, RN] and how rude he was over the weekend. He made several "inappropriate and aggressive" comments toward several individuals on the unit. He gave a patient the wrong meds on the unit. Overall rude and not appropriate with patients. Will forward info to DON. 4 patients signed.

An interview was conducted with the risk manager on 5/26/22 at 11:50 am. She said abuse allegations would only be reported if after the investigation they were substantiated. The patient advocate logs them. She doesn't remember the allegation. It was a month ago. An allegation does come to her. She doesn't think she had anything to do with it. It was unsubstantiated, so it wasn't abuse. She doesn't think it was abuse. He didn't curse or yell. It was more of a personality problem. She thinks it was inappropriate. He was rude. The intent falls on the line. She would have talked to the patients to get a better feel for this. If they had said more, like he was yelling at us, then she would do an investigation. He quit. It wasn't a good fit for him or this organization. The patient advocate investigates the patients' issues and resolves them.

An interview was conducted with the patient advocate on 5/26/22 at 12:00 pm. She said, "I don't know if I coded it correctly. I just coded it under what I thought it would be. There are not a lot of options. My impression was verbal abuse. I told the risk manager and the DON. I reported it in the Flash meeting at 10:00 am. I sent an email. I don't use incident reports. I give everything to risk management, verbally, or written in an email. One of the patients reported it. Then I spoke with Nurse S, RN. I did not speak with all four patients that signed this. I spoke to Nurse S, RN at the nurses' station and the conclusion was that he quit that day. I was not able to speak to him or get a statement. Nurse S, RN just said the patients came to her, and she heard him say some rude comments. No other forms were filled out. I did ask if an incident form was done, but I don't remember if that was done. I would report that to risk management so we could follow through with an investigation on that side. I told the risk manager. This was reported in Flash." The patient advocate said she usually emails it, so she has written proof that it was reported. "Sometimes I include the DON. He quit. So, it threw me off. Usually, we would get with the nurse and have a statement. I am not just the patient advocate. I am also the baker act coordinator. So, I was very busy. Not trying to excuse it. To talk to four patients is a lot. I didn't know where to go from there. The nurse quit. Nurse S, RN was very helpful. She gave me information on the nurse and her past interactions. It was anonymous. They listed people as witnesses. The risk manager is my supervisor. I report to her. This was definitely reported to her."

On 5/26/22 at 12:12 pm an interview was conducted with the CNO (chief nursing officer), who is the DON. She said "the nurse manager did a check-in with the nurse, [Nurse BB, RN.] I check in with the staff. If a staff was involved, I follow up with the staff member and the risk manager follows up with the patients. I don't check in on the patient. I am neutral. The risk manager should check in on the patient. I am a nurse so the patient may see me as taking the nurse's side, especially since I am their supervisor. We have had this happen in the past. The risk manager is supposed to check on the patients."

On 5/26/22 at 1:40 pm a follow up interview was conducted with the risk manager. She said the patient advocate spoke to the patients herself and found it to be unsubstantiated. Allegations are discussed if they are found to be credible. She investigates and then she puts it on the log and sums it up. It was unsubstantiated. The investigation is immediate. "They come up to me in real time and tell me there is an allegation. I remember [Nurse BB, RN] and that he was a problem, and I went to HR (Human Resources), and he was already gone. I usually go down and take statements and do my report. It was four days later. The incident reporting policy and the forms are in a folder on the nursing units. There is no official medication error. There is no investigation because it was unsubstantiated."

In a follow up interview with the CNO on 5/26/22 at 2:11 pm she said the risk manager reports to the CEO (chief executive officer). The CNO said this is her first time reading the complaint. She doesn't have anything about a medication error. She is present at the Flash meeting. "This is the patient advocate's signature, but the patient advocate doesn't attend Flash. There should have been an incident report for the medication error. There should have been follow up with the nurse. What was the medication, the dose, who was the patient? Was it their first error? There may need to be disciplinary action if it wasn't. Any type of abuse needs to be put in an incident report. We are going to go over the policy and streamline it so there is directions for each step." The CNO confirmed the policy says the CNO would suspend the staff member immediately and the CNO would be notified immediately.

Review of the policy, Abuse and Neglect, dated 4/2020,
It is the policy of the hospital that any staff who witness or suspect a patient has been abused either physically or verbally will report such abuse to the appropriate authority IMMEDIATELY. This includes patient-to-patient, staff to patient or suspicion that a patient may have been or is at risk for abuse, neglect and/or exploitation from caregivers, family, or others outside of the hospital. This suspicion may be based upon verbal report, visual observation, physical evidence or upon behaviors which provides reasonable belief that a patient may have been or may become a victim.
Procedure
1. Staff who witness or suspect the patient has been abused either physically or verbally will report such abuse to the administrator on call (AOC) IMMEDIATELY after notifying the appropriate authorities. This includes patient to patient or staff to patient abuse or neglect.
4. The staff member will be notified of the allegation and suspended from duty, pending results of the investigation.
c. The CEO and director of risk management will be notified immediately.
8. Investigation
a. Reports of abuse or neglect which occur while the patient is hospitalized will be thoroughly investigated by the risk manager or other staff assigned by the chief executive officer.
b. Interviews related to the investigation will be completed by the risk manager, human resources director, or the patient advocate, as assigned by the chief executive officer.

Based on review of facility policy, observation at the time of survey and staff interviews it was determined the facility failed to adhere to their current visitation policy.

Findings included:

Review of the facility Policy and Procedure title, "COVID-19 Response Plan", # IC-028, effective 01/2021
...Page 3 visitation Page 4
a. Effective Tuesday July 14, 2020, until further notice. The facility will implement visitor restriction for all services. Visitors will not be permitted in inpatient unless clinically necessary. In the event where visiting is deemed clinically necessary, there will be a screening process prior to entry. No children under the age of 18 will be permitted.
Review of the facility policy and procedures title, "Visitation/ Telephone", #PR1018, effective 11/12/2020 reviewed 07/2021 ...page 2 #5. Only two visitors will be allowed during visiting hours, unless authorized by the attending psychiatrist, clinical therapist and/or house supervisor.

Review of the facility website revealed no evidence of visitation on the website.

On 05/23/2022 at 9:30 am signage was observed posted on the front entrance door of the facility which stated, " ...Visitation with Patients Has Been Put on Hold Due to COVID-19 Safety Precautions ..." (photo evidence obtained)

On 05/23/2022 at 9:40 am an interview with staff Z revealed the facility does not allow patient visitation at this time.

On 5/23/2022 at 9:55 am the facility census was 96 patients.

On 05/24/2022 at 9:37 am an interview with the staff F revealed no visitation due to bed bug issues they had at the facility.

On 05/25/2022 at 9:56 am an interview with staff D revealed the facility does not have visitation due to staffing. Staff are need to ensure there is no contraband brought into the facility and to monitor patient visitation.

On 05/25/2022 at 9:56 am an interview with staff D revealed the policy for visitation, dated 07/2021, replaced the COVID 19 response Plan policy that restricted visitation, effective 01/2021.

An interview on 05/24/2022 at 10:10 am with staff I revealed the facility does not allow visitation and has not seen visitors for approximately 2 years or since the beginning of the COVID pandemic.

An interview on 05/24/2022 at 11:00 am with staff J revealed there is no visitation allowed. She stated the only visitors allowed are parole officers or someone from the command post. She did not remember observing regular visitation over past 2 to 3 years or since the beginning of the COVID pandemic.

On 05/24/2022 at 10:25 am an interview with Patient #18 revealed they are not allowed visitors.

An interview with patient #17 on 05/24/2022 at 10:45 am revealed the facility did not allow visitors.

On 05/26/2022 at 1:37 pm an interview with staff W revealed that the facility does not allow visitation currently, and she was unsure of the reason and assumed it was a corporate directive.

On 05/25/2022 at 9:56 am an interview conducted with Staff D confirmed the visitation policy, reviewed 07/2021, was the most current.

On 05/26/2022 at 11:32 am an interview conducted with Staff F confirmed the visitation policy, reviewed on 07/2021, superseded the COVID-19 Response Plan policy, effective 01/2021.

Based on observation, interview and record review the facility failed to:

1. Provide adequate numbers of licensed nurses and behavioral technicians (BHT) according to the facility prescribed staffing patterns and;
2. Follow facility and procedure on completing and documenting staffing assignments at the beginning of each shift.
These failures resulted in the increased potential for delayed response to individual patient needs and possible abuse/neglect.

Findings:

1. On 5/23/2022 at 10:55 am, a tour of the facility was conducted. The facility had five Nurses Stations or Units: Station A (Acute Unit), Station B (Substance Abuse Unit), Station C (Geriatric and Vulnerable Unit), Station G (General Unit) and Station M (Military Unit). The following was observed:
-Station A: there was one nurse and two BHTs
-Station B: there were two nurses and three BHTs
-Station C: there were two nurses and three BHTs
-Station G: there was one nurse and one BHT
-Station M: there was one nurse and one BHT

2. On 5/23/2022 at 11:05 a.m., the nurse assigned in Station A was asked to show the station's staffing sheet for review and was interviewed. The nurse stated she and two BHTs were assigned to work in the unit from 7 am to 7 pm The nurse stated, "The staffing assignment sheet is not filled up yet". The nurse stated the Station's census (number of patients) was 23. The nurse further stated they had one patient in the Station who required every five-minute monitoring while the remaining 22 required every 15-minute monitoring.

3. On 5/23/2022 at 12:51 am, staffing assignment for the day was reviewed with the Nurse Manager (NM). The NM stated they followed a "staffing grid document" (Nurse Service staffing patterns) that indicated the required nurses and BHTs for each census and Station identified by the facility to sufficiently meet the patient requirements for care.

4. On 05/24/2022 at 9:59 am, Station B was observed with the Chief Nursing Officer (CNO), there was no completed staffing assignment sheet for the shift.
On 05/24/2022 at 10:01 am, Station A was observed with the CNO, there was no completed staffing assignment sheet for the shift.
On 05/24/2022 at 10:03 am, Station C was observed with the CNO, there was no completed staffing assignment sheet for the shift.
On 05/24/2022 at 10:06 am, Station G was observed with the CNO, there was no completed staffing assignment sheet for the shift.

5. On 5/24/2022 at 10:07 am, the CNO was interviewed. The CNO stated the assignments sheets should have been completed first thing in the morning. The CNO further stated the sheet would have indicated to each staff what their assignments are for the shift.

6. On 5/24/2022 at 9:55 am staffing record, for 5/22/2022 7pm-7am through 5/22/2022, 7pm to 7am, was reviewed and compared to the staffing grid with the NM. The NM confirmed the following:

a. for 5/22/2022, 7pm-7am
Station A: census was 24, there two nurses and two BHT, missing one BHT (per staffing grid).
Station B: there was no staffing assignment sheet completed, census was 24, there were two nurses and two BHT, missing one BHT (per staffing grid).
Station C: there was no staffing assignment sheet completed, census was 22, there were two nurses and two BHTs, missing one BHT (per staffing grid).
Station G: there was no staffing assignment sheet completed, census was 11, there was one nurse and one BHT.
Station M: census was 15, there were two nurses, missing one BHT (per staffing grid).

b. for 5/22/2022, 7am-7pm
Station A: there was no staffing assignment sheet completed, census was 23, there were two nurses and two BHTs, missing one BHT (per staffing grid).
Station B: there was no staffing assignment sheet completed, census was 24, there were two nurses and three BHTs.
Station C: census was 22, there were two nurses and two BHTs, missing one BHT (per staffing grid).
Station M: there was no staffing assignment sheet completed, census was 15, there was nurse and one BHT, missing one nurse (per staffing grid).

c. for 5/21/2022, 7pm-7am
Station A: there was no staffing assignment sheet completed, census was 23, there were two nurses and two BHTs, missing one BHT (per staffing grid).
Station B: there was no staffing assignment sheet completed, census was 23, there were two nurses and one BHT, missing two BHTs (per staffing grid).
Station C: census was 21, there were two nurses and one BHT, missing two BHTs (per staffing grid).
Station G: there was no staffing assignment sheet completed, census was 11, there was one nurse and one BHT.
Station M: there was no staffing assignment sheet completed, census was 17, there was one nurse and one BHT, missing one nurse (per staffing grid).

d. for 5/21/2022, 7am-7pm
Station A: census 23, there were two nurses and two BHTs, missing one BHT (per staffing grid).
Station M: there was no staffing assignment sheet completed, census was 17, there were two nurses and one BHT.

e. for 5/20/2022 7pm-7am
Station B: there was no staffing assignment sheet completed, census was 18, there were two nurses and two BHTs.
Station C: there was no staffing assignment sheet completed, census was 21 - 2 RNs, three BHAs.
Station G: there was no staffing assignment sheet completed, census was 10, there was one nurse and one BHT.
Station M: there was no staffing assignment sheet completed, census was 17, there was one nurse and one BHT, missing one nurse (per staffing grid).

7. On 5/24/2022 at 11:04 a.m., the CNO was interviewed. The CNO stated the purpose of staffing assignment sheet was to "Identifying who is responsible for each patient, the level of observation required for patients, as well as who is responsible to for each task as it relates to the program." The CNO stated the staffing grid "Shows our minimum requirement for staff to patient ratio." The CNO stated if the staff to patient ration was not met, "There's a potential of quality of care to be decreased." The CNO stated they have been having staffing issues since February. The CNO further stated "There has been a decrease in the quality of care in the past months due to not meeting the ratios."

8. Review of the nursing policy and procedure, NS-1002 "Assignment of Nursing Staff," last reviewed 07/2021, indicated:
"Purpose: to provide guidance on nursing personnel staffing and assignments to ensure quality nursing care and a safe patient environment is maintained. Policy: to assure quality nursing care and safe patient environment ... Procedures: 1. Staffing assignments reflective of this policy will be completed at the beginning of each shift by the charge nurse. 2. Staffing assignments will be documented on the Staffing Assignment Sheet. 3. The name and title of the staff member to be assigned will be entered in the space provided 4. The names of the patients assigned to the staff members will be entered in the space provided 5. Break, mealtime and non-direct care assignments are to be included on the assignment sheet 6. It is the responsibility of each staff member to review his/her assignment when it is completed. 7. The assignment sheet will be available to staff throughout the shift. 8. The assignment sheet is to be forward to the CNO/ DON at the end of each shift. 9. The staffing assignment sheets will be reviewed and maintained by the CNO/ DON"

9. Review of the nursing policy and procedure, NS-1001 "Hospital Plan for Nursing Care," last reviewed 7/2021, indicated:
" ...Staffing Standards a. (hospital name) is responsible for assuring that each clinical unit has sufficient, competent nursing personnel to provide safe quality patient care, and for carrying out the goals and objectives of specific programs ...The Nurse Service staffing patterns are designed to meet continually changing patient requirements for care ..."