HospitalInspections.org

Based on review of policy and procedure, job description review, Abuse/Neglect/Exploitation log review, grievance file review,video footage review, medical record review, staffing schedule review and staff interview, the Governing Body failed to provide oversight and have systems in place to ensure the protection of patients' rights and an effective quality assessment and performance improvement program to ensure the safety of patients.

The findings include:

1. The facility failed to protect and promote patients' rights by failing to ensure care in a safe setting, prevent patient abuse and ensure a debriefing after the termination of restraints.

~cross refer to 482.13 Patient's Rights Condition: Tag A0115

2. The facility failed to implement and maintain an effective quality assessment and performance improvement program to ensure the safety of patients.

~cross refer to 482.21 QAPI Condition: Tag A0263

Based on review of policy and procedure, job description review, Abuse/Neglect/Exploitation log review, grievance file review,video footage review, medical record review, staffing schedule review and staff interview, the facility failed to protect and promote patients' rights by failing to ensure care in a safe setting, prevent patient abuse and ensure a debriefing after the termination of restraints.

The findings include:

1. The facility failed to provide care in a safe setting by failing to investigate an allegation of staff to patient abuse per facility policy for 1 of 4 sampled incidents of alleged patient abuse.

~cross refer to 482.13(c)(2) Patient's Rights Standard: Tag A0144

2. The facility failed to prevent patient abuse for 1 of 4 sampled incidents of alleged patient abuse.

~cross refer to 482.13(c)(3) Patient's Rights Standard: Tag A0145

3. The facility's nursing staff failed to ensure a debriefing was conducted after the termination of restraints per facility policy for 2 of 4 restraint records reviewed.

~cross refer to 482.13(e)(4)(ii) Patient's Rights Standard: Tag A0167

Based on review of policy and procedure, job description review, Abuse/Neglect/Exploitation log review, grievance file review,video footage review, medical record review, staffing schedule review and staff interview the facility failed to ensure a safe environment of care by failing to investigate an allegation of staff to patient abuse per facility policy for 1 of 4 sampled incidents of alleged patient abuse (#6).

The findings include:

Review of the facility's policy, "Abuse/Neglect/Exploitation of Patients, Prohibited", effective 01/13/2009, revealed "...Patients at XX Hospital are to be treated with dignity and respect. XX Hospital prohibits the abuse, neglect, and/or exploitation of patients...XX hospital recognizes that abuse, neglect, and/or exploitation of patients are a violation of the general statutes, patients rights, and the hospital's regulatory standards. Reporting and investigation procedures are to be strictly followed. ...PROCEDURES: I. IMMEDIATE INTERVENTION AND REPORTING REQUIREMENTS ... E. Documentation in the Medical Record 1. The ward RN (registered nurse) shall document the abuse...in a progress note in the patient's medical record prior to the end of the shift in which the report is received. ...F. Notifications Required by Immediate Supervisors/Designee, RNO Supervisor, or Advocate Any immediate supervisor/designee, RNO supervisor, or Advocate who receives a report of patient abuse...must immediately: 1. Complete the Initial Report of Abuse, Neglect, and/or Exploitation Form 2. Notify the following staff as applicable: a. XX Advocacy Department; b. Accused employee's Department Head/designee, Building Supervisor, or Nurse Manager; c. XX Nursing Office; d. Social Work Department Office; e. Patient's assigned social worker; ... II. ABUSE, NEGLECT, EXPLOITATION INVESTIGATION PROCESS ... B. Responsibilities of the Investigating Supervisor ... 2. The Investigating Supervisor shall arrange for and provide protective services for the patient during the investigatory period. (Management has the option to place the accused employee on investigatory status with pay, reassign duties, or maintain current assignment)...3.c. If the identify of the accused staff is unknown or the accused individual is health care personnel, the Investigating Supervisor must complete the Health Care Personnel Registry 24 Hour Initial Report...C. Responsibilities of the Investigation Team (Advocate and Investigating Supervisor) ...2. The Investigation Team shall complete and sign the Abuse, Neglect, and Exploitation Investigation Report within five (5) working days from initiation of investigation. ...".

Review of the current job description for an Advocate I revealed "I. ...B. Primary Purpose of Position: ...provides Advocacy services to their assigned facility 24 hours a day, seven days a week, 365 days a year. This is accomplished by providing technical assistance to facility staff, including monitoring, consulting and training in regards to rights issues, responding to complaints regarding services and investigating alleged rights violations. He/she assures that customers are represented at all levels of the assigned facility and that the facility's systems follow appropriate statutes, administrative codes and standards to uphold customers' human, civil and legal rights and meet the customers' needs for dignity, safety, care, treatment and habilitation. ... C. Work Schedule: ...a flexible schedule is required due to the unique needs of the customers being served. ...The Advocate I must be available to the facility and customers after hours for consultation, assessment of safety and comfort, guidance and to initiate investigations of possible rights violations as they arise. The availability of this Advocate I is ensured through a 24 hour on-call schedule...II. A. DESCRIPTION OF RESPONSIBILITIES AND DUTIES: ...When an allegation is received, the Advocate I immediately ensures that the customer(s) is/are protected from further/potential harm. The Advocate I then promptly conducts, in conjunction with facility management, an investigation into all allegations of mistreatment, abuse, neglect, exploitation, corporal punishment and other rights violations. ...In compliance with the Health Care Personnel Registry requirements, investigations are initiated within 24 hours and completed within 5 working days. Circumstances which prevent the completion of an investigation within the specified time frame must be clearly documented in the investigative report and the Advocate II must be made aware. ...".

Review of the Alleged Abuse/Neglect/Exploitation Incident Log on 04/27/2010 revealed for each case listed the log included the assigned advocate's name, the client's (patient's) name, unit and ward, the report date, the incident date, the category of the allegation (abuse, neglect or exploitation) and the outcome of the investigation (whether or not the allegation was substantiated). Review of the log revealed an allegation of abuse reported by Patient #8 on 04/05/2010. Further review of the log revealed documentation of the following entry: Advocate - (Patient Advocate #1), Client - (Patient #6), Unit/Ward - Adult/Acute 2 E (2 East), Report Date - 04/21/2010, Incident Date - Unknown and Allegation - physical abuse. Review of the log revealed no documentation of the outcome of the investigation.

Review of the patient grievance form completed by Patient #8 revealed "Staff is homophobic, racist, prejudice and not following procedures by withholding my medicine, also touch patients inappropriate". Review of the form further revealed "Hospital Staff/Treatment Team Review of Actions Taken: Contacted patient 4/8/10 @ (at) 3:45 pm to clarify grievance. He stated that he witness a staff member named Cory grab another patient (Mr. Martin), put him in a full Nelson (and) drag him down the hall. He stated that Mr. Martin is a homosexual and that the staff have been picking on him because of that. Contacted (name of director of patient advocacy) - Grievance upgraded to allegation". Further review of the grievance file for Patient #8 revealed a handwritten note by Patient #8 dated 04/08/2010 at 3:45 pm. Review of the note revealed, "Cory (volunteer) grab Mr. Martin (and) put him in a full Nelson (and) dragged him down. Mr. Martin is homosexual".

Open record review of Patient #6 revealed a 22 year-old admitted on 01/21/2010 with schizoaffective disorder, bipolar type and moderate mental retardation. Record review revealed a "Restrictive Intervention Progress Note" dated 04/07/2010 at 0905. Review revealed "Pt (patient) became argumentative and threatening RN. Pt pushing, intrusive and violating personal boundaries of staff. Staff attempted to redirect pt but unsuccessful. Pt continued. Pt refused injections ordered by MD (physician) for agitation. Pt was placed in hold for assaulting staff. Continued to threaten staff and swinging at staff once released from hold. Pt placed in restraints for danger to others." Review revealed Patient #6 was placed in a CPI (Crisis Prevention Institute) hold at 0905 by RN #1, LPN (Licensed Practical Nurse) #1 and MHT (mental health technician) #1. Review further revealed Patient #6 was placed in 4 point restraints at 0915 and was released at 1010. Further record review revealed a physician's order dated 04/07/2010 at 0900 for Benadryl 50 mg (milligrams) IM (intramuscular), Haldol 5 mg IM and Ativan 2 mg IM now. Review of the MAR (medication administration record) revealed the medication was administered at 0925.

Interview on 04/27/2010 at 1350 with Patient Advocate #1 revealed "(Patient #8) filed a grievance on April 5. He was interviewed on April 8 by Service Excellence (staff) and reported that staff put a patient in a full Nelson. He gave a name of a staff that doesn't work on that unit and gave the name of a patient that is not on that unit. Service excellence notified us that his grievance was being changed to an abuse allegation....I interviewed (Patient #8) on April 11. He gave me the same information. When he told me the patient was homosexual, I knew he was talking about (Patient #6)....I did not start the investigation until April 21 because I was off on April 15 and 16. The case load prevented me from really starting the investigation until April 21....We have meetings all day on Mondays and that keeps me from investigating on Mondays, too." Further interview revealed "When I realized it was probably (Patient #6) I pulled his restraint records and I watched the video yesterday afternoon (04/26/2010) of the unit on April 7. It (the video) is not a pretty thing. (Patient #6) fell on the floor, staff grabbed him by his arms and drug him to the restraint room. They were not using CPI technique. Then a staff member, (MHT #1), put a pillow over his face." Interview revealed, "we have 3 advocates plus a supervisor. Usually, once we get an allegation, we're on it but this was different." Interview confirmed the policy for the investigation of an allegation of patient abuse to be started immediately was not followed.

Review of the video with Patient Advocate #1 and administrative staff on 04/27/2010 at 1420 of the unit where Patient #6 and #8 were located (Adult/Acute 2 East) on 04/07/2010 revealed the following:
? 0843 Patient #6 in the Day Room
? 0844 Patient #6 walking to Nurse's Station
? 0846 Patient #6 outside Nurse's Station
? 0848 Patient #6 talking to unit director
? 0852 Patient #6 walking between Day Room and Nurse's Station
? 0859 Patient #6 fell of sofa in Day Room, MHT#1 is with Patient #6
? 0901 Patient #6 outside Nurse's Station with RN #1
? 0911 Patient #6 on floor outside Nurse's Station, dragged into bathroom by MHC #1 and LPN #1 with arms pulled above head, patient on back
? 0912 RN #1 at bathroom door
? 0914 Patient #6 came out of bathroom and threw shoes against the wall
? 0915 Patient #6 on floor in front of Nurse's Station, dragged to restraint room by MHT #1 and LPN #1 with arms pulled above head, patient on back ; RN #1 following
? 0916 MHT #1 removed pillow from behind Patient #6's head, put pillow over Patient #6's face
? 0917 Patient #6 threw pillow off his face
? 0918 Patient #6 in 4 point restraints with MHT #1 in restraint room.

Video review revealed Patient #8 standing in hall, watching the incident until Patient #6 is dragged into the restraint room. Review of the video revealed no evidence that Patient #6 assaulted staff prior to being placed in restraints.

Interview on 04/28/2010 at 0840 with the Director of Patient Advocacy revealed "When there is an allegation of abuse, we have 5 days to investigate. This is a CMS requirement." Interview further revealed, "Allegations of abuse, neglect and exploitation fall into a different category than complaints. They are top priority....A 24 hour initial report must be completed within 24 hours of the allegation being made. Advocates are on call 24/7 and initial reports should be completed, even on the weekend or if the regular (assigned) advocate staff is off....The expectation is that investigations are done (completed) within 5 days of the allegation....It (allegation of abuse of Patient #6) should have been investigated before the (April) 21st." Interview further revealed, "Someone needed to follow up with (Patient #8) to find out who the patient was (that he said was dragged down the hall). That's the piece that is missing." Interview confirmed that the investigation of alleged staff abuse to Patient #6 should have started prior to 04/21/2010.

Interview on 04/28/2010 at 1040 with the director of nursing revealed "I found out about this on Monday (04/26/2010). The Advocacy secretary called the nursing office secretary with a message that I should review a video. I reviewed the video yesterday (04/27/2010) and immediately called the Advocacy office to let them know the 3 staff members involved needed to be placed on investigatory leave." Interview further revealed, "I am very concerned about the time frame involved in this investigation. The process was not followed and the staff members worked until yesterday."

Review of the staffing schedule revealed RN #1 staffed a patient unit on 04/15/2010, 04/16/2010, 04/17/2010, 04/18/2010, 04/19/2010 and 04/20/2010 (6 shifts after the alleged abuse of Patient #6). Review of the staffing schedule revealed LPN #1 staffed a patient unit on 04/09/2010, 04/12/2010, 04/13/2010, 04/14/2010, 04/15/2010, 04/17/2010, 04/18/2010 and 04/27/2010 (8 shifts after the alleged abuse of Patient #6). Review of the staffing schedule revealed MHT #1 staffed a patient unit on 04/08/2010, 04/09/2010, 04/12/2010, 04/13/2010, 04/14/2010, 04/16/2010, 04/16/2010, 04/17/2010, 04/18/2010, 04/19/2010, 04/21/2010, 04/22/2010, 04/26/2010 and 04/27/2010 (13 shifts after the alleged abuse of Patient #6).

Review of hospital documents revealed RN #1, LPN #1 and MHT #1 were placed on investigatory leave on 04/27/2010 (19 days after alleged abuse of Patient #6).

Based on review of policy and procedure, Abuse/Neglect/Exploitation log review, medical record review, video footage review and staff interview the facility failed to prevent patient abuse for 1 of 4 sampled incidents of alleged patient abuse (#6).

The findings include:

Review of the facility's policy, "Abuse/Neglect/Exploitation of Patients, Prohibited", effective 01/13/2009, revealed "...Patients at XX Hospital are to be treated with dignity and respect. XX Hospital prohibits the abuse, neglect, and/or exploitation of patients...XX hospital recognizes that abuse, neglect, and/or exploitation of patients are a violation of the general statutes, patients rights, and the hospital's regulatory standards...."

Review of the Alleged Abuse/Neglect/Exploitation Incident Log on 04/27/2010 revealed for each case listed the log included the assigned advocate's name, the client's (patient's) name, unit and ward, the report date, the incident date, the category of the allegation (abuse, neglect or exploitation) and the outcome of the investigation (whether or not the allegation was substantiated). Review of the log revealed documentation of the following entry: Advocate - (Patient Advocate #1), Client - (Patient #6), Unit/Ward - Adult/Acute 2 E (2 East), Report Date - 04/21/2010, Incident Date - Unknown and Allegation - physical abuse. Review of the log revealed no documentation of the outcome of the investigation.

Open record review of Patient #6 revealed a 22 year-old male admitted on 01/21/2010 with schizoaffective disorder, bipolar type and moderate mental retardation. Record review revealed a "Restrictive Intervention Progress Note" dated 04/07/2010 at 0905. Review revealed "Pt (patient) became argumentative and threatening RN. Pt pushing, intrusive and violating personal boundaries of staff. Staff attempted to redirect pt but unsuccessful. Pt continued. Pt refused injections ordered by MD (physician) for agitation. Pt was placed in hold for assaulting staff. Continued to threaten staff and swinging at staff once released from hold. Pt placed in restraints for danger to others." Review revealed Patient #6 was placed in a CPI (Crisis Prevention Institute) hold at 0905 by RN #1, LPN (Licensed Practical Nurse) #1 and MHT (mental health technician) #1. Review further revealed Patient #6 was placed in 4 point restraints at 0915 and was released at 1010. Further record review revealed a physician's order dated 04/07/2010 at 0900 for Benadryl 50 mg (milligrams) IM (intramuscular), Haldol 5 mg IM and Ativan 2 mg IM now. Review of the MAR (medication administration record) revealed the medication was administered at 0925.

Review of the video with Patient Advocate #1 and administrative staff on 04/27/2010 at 1420 of the unit where Patient #6 was located on 04/07/2010 (Adult/Acute 2 East) revealed the following:
? 0843 Patient #6 in the Day Room
? 0844 Patient #6 walking to Nurse's Station
? 0846 Patient #6 outside Nurse's Station
? 0848 Patient #6 talking to unit director
? 0852 Patient #6 walking between Day Room and Nurse's Station
? 0859 Patient #6 fell of sofa in Day Room, MHT#1 is with Patient #6
? 0901 Patient #6 outside Nurse's Station with RN #1
? 0911 Patient #6 on floor outside Nurse's Station, dragged into bathroom by MHC #1 and LPN #1 with arms pulled above head, patient on back
? 0912 RN #1 at bathroom door
? 0914 Patient #6 came out of bathroom and threw shoes against the wall
? 0915 Patient #6 on floor in front of Nurse's Station, dragged to restraint room by MHT #1 and LPN #1 with arms pulled above head, patient on back ; RN #1 following
? 0916 MHT #1 removed pillow from behind Patient #6's head, put pillow over Patient #6's face
? 0917 Patient #6 threw pillow off his face
? 0918 Patient #6 in 4 point restraints with MHT #1 in restraint room.

Review of the video revealed no evidence that Patient #6 assaulted staff prior to being placed in restraints.

Interview on 04/27/2010 at 1350 with Patient Advocate #1 revealed "...I watched the video yesterday afternoon (04/26/2010) of the unit on April 7. It (the video) is not a pretty thing. (Patient #6) fell on the floor, staff grabbed him by his arms and drug him to the restraint room. They were not using CPI technique. Then a staff member, (MHT #1), put a pillow over his face." Interview revealed "The abuse will be substantiated."

Interview on 04/28/2010 at 1040 with the director of nursing revealed "I was shocked when I saw the video. I was so disappointed in our staff." Interview confirmed that Patient #6 was abused by RN #1, LPN #1 and MHT #1. Interview revealed that RN #1, LPN #1 and MHT #1 were placed on investigatory leave 04/27/2010.

RN #1, LPN #1 and MHT #1 were not available for interview.

Based on review of facility policy, medical record review and staff interviews the facility's nursing staff failed to ensure a debriefing was conducted after the termination of restraints per facility policy for 2 of 4 restraint records reviewed (#2, 6).

The findings include:

Review of the facility policy, "Restrictive Interventions", effective 05/18/2009, revealed "...VIII. Debriefing The purpose of the debriefing is to work to eliminate the future use of restrictive interventions. A. Within 24 hours of the patient's release from a restrictive intervention, the RN (Registered Nurse) conducts a debriefing regarding the use of the restrictive intervention. B. Debriefing includes: 1. Involvement of the patient, the patient's family/Legally Responsible Person where appropriate, and the staff who were involved in the episode, if available; 2. Identification of what led to the restrictive intervention and what could have been handled differently to help prevent the use of the restrictive intervention; 3. Review of alternatives to seclusion or restraint and why these could not be used or did not work; 4. Review of how the individual's physical well-being, psychological comfort, and right to privacy were maintained during the restrictive intervention 5. Assessment of the learning that occurred by the staff and the patient; and 6. Counseling of the patient for any physical or psychological trauma may have resulted from the restrictive intervention. C. Debriefing information is communicated at the next morning board review. D. Debriefing is documented on the Restrictive Intervention Progress Note. E. Information obtained and documented from debriefing is analyzed and categorized for use in improving the process and in annual staff training...."

1. Open record review of Patient #2 revealed a 23 year-old admitted 04/22/2010 with schizophrenia. Record review revealed a "Restrictive Intervention Progress Note" dated 04/23/2010 at 1325. Review of the restrictive intervention progress note revealed Patient #2 was placed in a CPI (Crisis Prevention Institute) hold at 1325 and was released at 1327. Review of the debriefing section of the restrictive intervention note revealed the section was blank.

Interview on 04/27/2010 at 1600 with administrative nursing staff revealed, "Debriefing should be done within 24 hours of any restrictive intervention. The nurse pulls the staff together to talk about the incident and individualize patient care." Interview confirmed a debriefing was not conducted after Patient #2 was placed in a CPI hold on 04/23/2010. Interview confirmed the nursing staff did not follow the follow the facility's Restrictive Interventions policy.

2. Open record review of Patient #6 revealed a 22 year-old admitted on 01/21/2010 with schizoaffective disorder, bipolar type and moderate mental retardation. Record review revealed a "Restrictive Intervention Progress Note" dated 04/07/2010 at 0905. Review revealed Patient #6 was placed in a CPI (Crisis Prevention Institute) hold at 0905. Review further revealed Patient #6 was placed in 4 point restraints at 0915 and was released at 1010. Review of the debriefing section of the restrictive intervention note revealed the section was blank.

Interview on 04/27/2010 at 1600 with administrative nursing staff revealed "Debriefing should be done within 24 hours of any restrictive intervention. The nurse pulls the staff together to talk about the incident and individualize patient care." Interview confirmed a debriefing was not conducted after Patient #6 was placed in a CPI hold and 4-point restraints on 04/07/2010. Interview confirmed the nursing staff did not follow the follow the facility's Restrictive Interventions policy.

Based on policy review, grievance form review, staff interview and Alleged Abuse/Neglect/Exploitation Incident Log review, the facility failed to implement and maintain an effective quality assessment and performance improvement program to ensure the safety of patients.

The findings include:

1. The facility failed to have a system in place to ensure allegations of abuse were investigated per policy for 1 of 4 sampled incidents of alleged patient abuse.

~cross refer to 482.21(a)(2) QAPI Standard: Tag A0267

Based on policy review, grievance form review, staff interview and Alleged Abuse/Neglect/Exploitation Incident Log review, the facility failed to have a system in place to ensure allegations of abuse were investigated per policy for 1 of 4 sampled incidents of alleged patient abuse (Patient #6).

The findings include:

Review of the facility's policy, "Abuse/Neglect/Exploitation of Patients, Prohibited", effective 01/13/2009, revealed "...XX Hospital prohibits the abuse, neglect, and/or exploitation of patients...XX hospital recognizes that abuse, neglect, and/or exploitation of patients are a violation of the general statutes, patients rights, and the hospital's regulatory standards. Reporting and investigation procedures are to be strictly followed....PROCEDURES: I. IMMEDIATE INTERVENTION AND REPORTING REQUIREMENTS.... F. Notifications Required by Immediate Supervisors/Designee, RNO Supervisor, or Advocate Any immediate supervisor/designee, RNO supervisor, or Advocate who receives a report of patient abuse...must immediately: 1. Complete the Initial Report of Abuse, Neglect, and/or Exploitation Form 2. Notify the following staff as applicable: a. XX Advocacy Department; b. Accused employee's Department Head/designee, Building Supervisor, or Nurse Manager; c. XX Nursing Office; d. Social Work Department Office; e. Patient's assigned social worker.... II. ABUSE, NEGLECT, EXPLOITATION INVESTIGATION PROCESS.... B. Responsibilities of the Investigating Supervisor....2. The Investigating Supervisor shall arrange for and provide protective services for the patient during the investigatory period. (Management has the option to place the accused employee on investigatory status with pay, reassign duties, or maintain current assignment)....3.c. If the identify of the accused staff is unknown or the accused individual is health care personnel, the Investigating Supervisor must complete the Health Care Personnel Registry 24 Hour Initial Report...C. Responsibilities of the Investigation Team (Advocate and Investigating Supervisor) ....2. The Investigation Team shall complete and sign the Abuse, Neglect, and Exploitation Investigation Report within five (5) working days from initiation of investigation...."

Review of the patient grievance form completed by Patient #8 revealed "Staff is homophobic, racist, prejudice and not following procedures by withholding my medicine, also touch patients inappropriate". Review of the form further revealed "Hospital Staff/Treatment Team Review of Actions Taken: Contacted patient 4/8/10 @ (at) 3:45 pm to clarify grievance. He stated that he witness a staff member named Cory grab another patient (Mr. Martin), put him in a full Nelson (and) drag him down the hall. He stated that Mr. Martin is a homosexual and that the staff have been picking on him because of that. Contacted (name of director of patient advocacy) - Grievance upgraded to allegation". Further review of the grievance file for Patient #8 revealed a handwritten note by Patient #8 dated 04/08/2010 at 3:45 pm. Review of the note revealed, "Cory (volunteer) grab Mr. Martin (and) put him in a full Nelson (and) dragged him down. Mr. Martin is homosexual".

Interview on 04/27/2010 at 1350 with Patient Advocate #1 revealed "(Patient #8) filed a grievance on April 5. He was interviewed on April 8 by Service Excellence (staff) and reported that staff put a patient in a full Nelson. He gave a name of a staff that doesn't work on that unit and gave the name of a patient that is not on that unit. Service excellence notified us that his grievance was being changed to an abuse allegation....I interviewed (Patient #8) on April 11. He gave me the same information. When he told me the patient was homosexual, I knew he was talking about (Patient #6)....I did not start the investigation until April 21 because I was off on April 15 and 16. The case load prevented me from really starting the investigation until April 21....We have meetings all day on Mondays and that keeps me from investigating on Mondays, too." Further interview revealed "When I realized it was probably (Patient #6) I pulled his restraint records and I watched the video yesterday afternoon (04/26/2010) of the unit on April 7. It (the video) is not a pretty thing. (Patient #6) fell on the floor, staff grabbed him by his arms and drug him to the restraint room. They were not using CPI technique. Then a staff member, (MHT #1), put a pillow over his face." Interview revealed, "We have 3 advocates plus a supervisor. Usually, once we get an allegation, we're on it but this was different." Interview confirmed the policy for the investigation of an allegation of patient abuse to be started immediately was not followed.

Interview on 04/28/2010 at 0840 with the Director of Patient Advocacy revealed "When there is an allegation of abuse, we have 5 days to investigate. This is a CMS requirement." Interview further revealed, "Allegations of abuse, neglect and exploitation fall into a different category than complaints. They are top priority....A 24 hour initial report must be completed within 24 hours of the allegation being made. Advocates are on call 24/7 and initial reports should be completed, even on the weekend or if the regular (assigned) advocate staff is off....The expectation is that investigations are done (completed) within 5 days of the allegation....It (allegation of abuse of Patient #6) should have been investigated before the (April) 21st." Interview further revealed, "Someone needed to follow up with (Patient #8) to find out who the patient was (that he said was dragged down the hall). That's the piece that is missing." Interview confirmed that the investigation of alleged staff abuse to Patient #6 should have started prior to 04/21/2010.

Interview on 04/28/2010 at 1040 with the director of nursing revealed "I found out about this on Monday (04/26/2010). The Advocacy secretary called the nursing office secretary with a message that I should review a video. I reviewed the video yesterday (04/27/2010) and immediately called the Advocacy office to let them know the 3 staff members involved needed to be placed on investigatory leave." Interview further revealed, "I am very concerned about the time frame involved in this investigation. The process was not followed and the staff members worked until yesterday."

Review of the Alleged Abuse/Neglect/Exploitation Incident Log on 04/27/2010 revealed for each case listed the log included the assigned advocate's name, the client's (patient's) name, unit and ward, the report date, the incident date, the category of the allegation (abuse, neglect or exploitation) and the outcome of the investigation (whether or not the allegation was substantiated). Review of the log revealed documentation of the following entry: Advocate - (Patient Advocate #1), Client - (Patient #6), Unit/Ward - Adult/Acute 2 E (2 East), Report Date - 04/21/2010, Incident Date - Unknown and Allegation - physical abuse. Review of the log revealed no documentation of the outcome of the investigation.

Interview on 04/28/2010 at 1545 with the Compliance Officer revealed an initial investigation report should be completed within 24 hours after an allegation of abuse, neglect or exploitation had been made. Interview revealed on 04/08/2010 Service Excellence staff reported to advocacy that Patient #8 reported he had witnessed staff drag a patient down the hall on the Adult/Acute 2 East Ward. Interview revealed the staff member's name given to the Service Excellence staff by the patient was not the name of any staff on the Adult/Acute 2 East Ward and the patient had not given a date or time of the alleged incident. Interview revealed Patient Advocate #1 interviewed Patient #8 on 04/11/2010 (3 days after the allegation was reported to advocacy), at which time the patient told the advocate the patient he had witnessed being dragged down the hall was homosexual. Interview revealed on 04/21/2010 Patient Advocate #1 completed an initial report of the allegation of abuse (13 days after the allegation was reported to advocacy). Further interview revealed the Alleged Abuse/Neglect/Exploitation Incident Log was used by the Advocacy Department to track allegations of abuse, neglect and exploitation. Interview revealed the Director of Patient Advocacy used the log to monitor the length of time from the beginning of an investigation (Report Date) until the end of an investigation (Outcome Date) and reported the data to the Performance Improvement (PI) Department. Interview revealed PI then reviewed the data and converted it into graphs to show the length of investigation times. Interview revealed the "Report Date" listed on the log was generated when the assigned advocate completed the initial investigation report. Interview confirmed the log listed 04/21/2010 as the Report Date for the allegation of abuse involving Patient #6 (13 days after the allegation was reported to the advocate). Interview revealed the hospital did not track the length of time it took to initiate an investigation after an allegation of abuse, neglect or exploitation had been made.

Based on policy and procedure, Abuse/Neglect/Exploitation log review, medical record review, video footage review and staff interview the hospital's nursing staff failed to have an organized nursing service providing oversight of day-to-day operations to ensure supervision and monitoring of the delivery of care.

The findings include:

1. The hospital's nursing staff failed to monitor and supervise the delivery of patient care by failing to prevent staff to patient abuse for 1 of 4 sampled patients (#6).

~cross refer to 482.23 (b)(3) Nursing Services Standard: Tag A0395

2. The hospital's nursing staff failed to monitor and evaluate patient care by failing to ensure patients' weights were obtained as ordered by the physician for 2 of 2 sampled patients with physician's orders for weekly weights (#7 and #10).

~cross refer to 482.23 (b)(3) Nursing Services Standard: Tag A0395

Based on review of policy and procedure, Abuse/Neglect/Exploitation log review, medical record review, video footage review and staff interview facility staff failed to monitor and supervise patients to prevent staff to patient abuse for 1 of 4 sampled incidents of alleged patient abuse (#6). Facility staff failed to monitor the delivery of care to ensure weights were obtained as ordered by the physician for 2 of 2 sampled patients with weekly weights (#7 and #10).

The findings include:

1. Review of the facility's policy, "Abuse/Neglect/Exploitation of Patients, Prohibited", effective 01/13/2009, revealed "...Patients at XX Hospital are to be treated with dignity and respect. XX Hospital prohibits the abuse, neglect, and/or exploitation of patients...XX hospital recognizes that abuse, neglect, and/or exploitation of patients are a violation of the general statutes, patients rights, and the hospital's regulatory standards...."

Review of the Alleged Abuse/Neglect/Exploitation Incident Log on 04/27/2010 revealed for each case listed the log included the assigned advocate's name, the client's (patient's) name, unit and ward, the report date, the incident date, the category of the allegation (abuse, neglect or exploitation) and the outcome of the investigation (whether or not the allegation was substantiated). Review of the log revealed documentation of the following entry: Advocate - (Patient Advocate #1), Client - (Patient #6), Unit/Ward - Adult/Acute 2 E (2 East), Report Date - 04/21/2010, Incident Date - Unknown and Allegation - physical abuse. Review of the log revealed no documentation of the outcome of the investigation.

Open record review of Patient #6 revealed a 22 year-old male admitted on 01/21/2010 with schizoaffective disorder, bipolar type and moderate mental retardation. Record review revealed a "Restrictive Intervention Progress Note" dated 04/07/2010 at 0905. Review revealed "Pt (patient) became argumentative and threatening RN. Pt pushing, intrusive and violating personal boundaries of staff. Staff attempted to redirect pt but unsuccessful. Pt continued. Pt refused injections ordered by MD (physician) for agitation. Pt was placed in hold for assaulting staff. Continued to threaten staff and swinging at staff once released from hold. Pt placed in restraints for danger to others." Review revealed Patient #6 was placed in a CPI (Crisis Prevention Institute) hold at 0905 by RN #1, LPN (Licensed Practical Nurse) #1 and MHT (mental health technician) #1. Review further revealed Patient #6 was placed in 4 point restraints at 0915 and was released at 1010. Further record review revealed a physician's order dated 04/07/2010 at 0900 for Benadryl 50 mg (milligrams) IM (intramuscular), Haldol 5 mg IM and Ativan 2 mg IM now. Review of the MAR (medication administration record) revealed the medication was administered at 0925.

Review of the video with Patient Advocate #1 and administrative staff on 04/27/2010 at 1420 of the unit where Patient #6 was located on 04/07/2010 (Adult/Acute 2 East) revealed the following:
? 0843 Patient #6 in the Day Room
? 0844 Patient #6 walking to Nurse's Station
? 0846 Patient #6 outside Nurse's Station
? 0848 Patient #6 talking to unit director
? 0852 Patient #6 walking between Day Room and Nurse's Station
? 0859 Patient #6 fell of sofa in Day Room, MHT#1 is with Patient #6
? 0901 Patient #6 outside Nurse's Station with RN #1
? 0911 Patient #6 on floor outside Nurse's Station, dragged into bathroom by MHC #1 and LPN #1 with arms pulled above head, patient on back
? 0912 RN #1 at bathroom door
? 0914 Patient #6 came out of bathroom and threw shoes against the wall
? 0915 Patient #6 on floor in front of Nurse's Station, dragged to restraint room by MHT #1 and LPN #1 with arms pulled above head, patient on back ; RN #1 following
? 0916 MHT #1 removed pillow from behind Patient #6's head, put pillow over Patient #6's face
? 0917 Patient #6 threw pillow off his face
? 0918 Patient #6 in 4 point restraints with MHT #1 in restraint room.

Review of the video revealed no evidence that Patient #6 assaulted staff prior to being placed in restraints.

Interview on 04/27/2010 at 1350 with Patient Advocate #1 revealed "...I watched the video yesterday afternoon (04/26/2010) of the unit on April 7. It (the video) is not a pretty thing. (Patient #6) fell on the floor, staff grabbed him by his arms and drug him to the restraint room. They were not using CPI technique. Then a staff member, (MHT #1), put a pillow over his face." Interview revealed "The abuse will be substantiated."

Interview on 04/28/2010 at 1040 with the director of nursing revealed "I was shocked when I saw the video. I was so disappointed in our staff." Interview confirmed that Patient #6 was abused by RN #1, LPN #1 and MHT #1. Interview revealed that RN #1, LPN #1 and MHT #1 were placed on investigatory leave 04/27/2010.

RN #1, LPN #1 and MHT #1 were not available for interview.



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2. Medical record review on 04/27/2010 for Patient #7 revealed a 45 year-old male that was admitted on 08/14/2009 with paranoid schizophrenia. Record review revealed a physician's order dated 08/20/2009 at 1630 for weekly weights. Record review revealed no documentation nursing staff monitored the patient's weight during the following weeks: 08/23-29/2009, 10/11-17/2009, 10/18-24/2009, 10/25-31/2009, 11/08-14/2009, 11/22-28/2009, 11/29/2009-12/05/2009, 12/20-26/2009, 01/03-09/2010, 01/17-23/2010, 01/24-30/2010, 03/28/2010-04/03/2010, 04/04-10/2010 and 04/18-24/2010 (14 of 36 weeks reviewed).

Interview on 04/28/2010 at 1545 with the Nurse Manager of the unit where Patient #7 was located revealed nursing staff must follow physician's orders to monitor patients' weights. Interview revealed the Mental Health Technician (MHT) staff usually weighed all patients that were due to be weighed on Saturday each week. Interview revealed the licensed nursing staff were responsible for ensuring the weights were done per physician's orders. Further interview revealed the licensed nursing staff should review all patients' weights and compare them to previous weights to assess for excessive gains or losses.

Interview confirmed there was no available documentation that nursing staff monitored the patient's weight during the following weeks: 08/23-29/2009, 10/11-17/2009, 10/18-24/2009, 10/25-31/2009, 11/08-14/2009, 11/22-28/2009, 11/29/2009-12/05/2009, 12/20-26/2009, 01/03-09/2010, 01/17-23/2010, 01/24-30/2010, 03/28/2010-04/03/2010, 04/04-10/2010 and 04/18-24/2010 (14 of 36 weeks reviewed).

3. Medical record review on 04/28/2010 for Patient #10 revealed a 46 year-old male that was admitted on 05/02/2009 with schizoaffective disorder - bipolar type. Record review revealed a physician's order dated 03/30/2010 at 1615 for weekly weights. Record review revealed no documentation nursing staff monitored the patient's weight during the week of 04/04-10/2010 (1 of 4 weeks reviewed).

Interview on 04/28/2010 at 1545 with the Nurse Manager of the unit where Patient #10 was located revealed nursing staff must follow physician's orders to monitor patients' weights. Interview revealed the Mental Health Technician (MHT) staff usually weighed all patients that were due to be weighed on Saturday each week. Interview revealed the licensed nursing staff were responsible for ensuring the weights were done per physician's orders. Further interview revealed the licensed nursing staff should review all patients' weights and compare them to previous weights to assess for excessive gains or losses.

Interview confirmed there was no available documentation that nursing staff monitored the patient's weight during the week of 04/04-10/2010 (1 of 4 weeks reviewed).


NC00063713