HospitalInspections.org

Based on record review and interview, the hospital failed to ensure that patients received care in a safe setting as evidenced by the hospital allowing 1 (S8BHT) of 7 staff members who witnessed and/or participated in abuse to continue to work in the hospital with no re-training conducted regarding the incident. S8BHT restrained a patient while the patient was being physically abused by another staff member and failed to intervene or report the abuse.
Findings:

Review of the hospital policy titled, Self-Reporting Process for Allegations of Abuse/Neglect to a Patient Involving Employees, revealed it included the following. It is the responsibility of all staff, partners, consultants and students to report any allegations of abuse and/or neglect that involves employees of this facility.

Review of the electronic medical record for Patient #1 revealed he was admitted the hospital's psychiatric unit on 11/17/20 with a diagnosis of bipolar disorder. Further review of the medical record revealed that the patient had surgery on his left eye on 12/29/20 to repair an orbital fracture.

Review of the hospital's documented investigation of an incident involving Patient #1 on 12/20/20 revealed that video recordings of the incident were viewed by hospital administration and director of hospital security. The documentation of the video review revealed that on 12/20/20 at 10:39 p.m., S9BHT begins to exit Patient #1's room then turns and strikes patient's right jaw with left hand, closed fist. LPN is stationed in the patient's doorway. Further review of the video review documentation revealed that at 10:42 p.m., techs aggressively take patient down upon the bed and S9BHT appears to strike the patient in the head/face as the other techs begin to physically restrain and/or apply restraints. Two nurses are standing immediately outside of entryway. The documentation of video review revealed that S9BHT stuck the patient a total of 11 times while the other 3 BHTs (including S8BHT) were in the room restraining the patient and nursing staff was standing immediately outside of doorway.

Further review of the investigation revealed that 6 of the 7 staff who were involved in the incident were terminated. S9BHT was arrested and charged with Battery of the Infirmed. Further review of the investigation revealed that S8BHT (hire date 08/10/20) was identified as being one of the BHTs the room restraining the patient during the incident. During interview, S8BHT was the only employee that accurately described what was viewed in the video. He stated he did not know what to do while in the room. He feared being bullied by the team if he reported it. S8BHT was suspended for 5 days.

On 01/08/21 at 9:30 a.m., interview with S3Consultant and S2Nurse Manager revealed that all staff on the psychiatric unit were re-inserviced regarding abuse/neglect. When asked how this was conducted, S2Nurse Manager stated that she performs "huddles" every week with the staff and stated she went over this information on the huddles dated 12/30/20 and 01/06/21. When asked if S8BHT received any more training or increased supervision after the incident on 12/20/20 besides the "huddles", they stated no.

Review of the "huddle" documentation dated 12/30/20 revealed a sign in sheet with multiple policies attached to it. These policies included seclusion/restraint, code green/CPI, patient rights, patient hand-off and threat of violence and duty to warn. S8BHT's signature was on this sign-in sheet.

Review of the "huddle" documentation dated 01/06/21 revealed a sign-in sheet with multiple policies attached to it including how to submit an SOS event, professional boundaries, video surveillance and nursing documentation rules and regulations. S8BHT's signature was on the sign-in sheet.

On 01/08/21 at 1:30 p.m., a telephone interview was conducted with S8BHT. When asked if he had received any training after the incident on 12/20/20, he stated no. When informed him that his signatures were on the "huddle" sign in sheets on 12/20/20 and 01/06/21, he stated that he signed the sheet because he was asked to. Further interview with S8BHT revealed that he was suspended for 5 days after the incident and told he could resume his normal work responsibilities on 12/25/20.