HospitalInspections.org

Based on review of medical records, review of facility documents and interview with staff, it was determined that the facility failed to immediately remove a Registered Nurse (RN) from patient care while investigating allegations of the RN physically abusing a patient, and failed to complete a medical evaluation of the patient that was a victim of physical abuse (A0145).

As a result of this failure, Immediate Jeopardy (IJ) was identified, and the facility was notified on November 22, 2022, at 2:25 PM. The facility submitted and implemented an acceptable plan to remove the IJ, that was verified on site by the State Survey Agency on November 28, 2022, at 1:35 PM.

The following interventions were implemented to resolve the IJ:
- Re-education of all hospital staff on abuse, neglect, and exploitation
- Education to all staff regarding reporting allegations of abuse, completing incident reports, increased supervision by Nursing Coordinators, new protocol for suspension of staff pending investigations regarding allegations of abuse, and training for hospital leaders regarding significant event management.
- Education was completed by all staff members prior to beginning their next scheduled shifts.
- State surveyors verified training, and reviewed attestations and testing completed by staff.

Staff were interviewed on November 28, 2022, and able to verbalize understanding of education received.

Based on review of video surveillance, document review, record review, and staff interview, it was determined that for 1 of 5 patients (Patient #2), the hospital failed to ensure the patient's right to be free from abuse, by failing to promptly report alleged physical abuse by RN A, and failing to immediately suspend RN A after the incident was reported, thus allowing continued access to all patients.

I. Hospital policy and document review

Hospital document titled "Adult Program Handbook" stated, "...You have the right to be safe from harm by other patients or staff...No one who works for MeadowWood Behavioral Health System is allowed to hit you, yell at you, call you names, or abuse you..."

Hospital policy titled "Patient Neglect, Abuse, Exploitation By Staff" stated, "...MeadowWood Behavioral Health System has a "Zero Tolerance" policy and does not condone any action that can be construed as neglect, abuse, and/or exploitation...Any employee who fails to report...patient...abuse is subject to disciplinary action...Director of Clinical Services or On Call Administrator, contacts the staff member...informs him/her of allegation and the need for temporary suspension...until investigation is completed..."

Hospital policy titled "Nursing Accountability" stated, "...RN's and LPN's are primarily responsible for the overall safety...of individual patients..."

II. Video Surveillance review

Video surveillance from D West on 11/14/22, at the following times, revealed:
- 06:24.06 AM - Patient #2 throws a towel at Registered Nurse (RN) A. RN A pushes Patient #2 into a chair 4 times.
- 06:24.10 AM - RN A puts Patient #2 in a choke hold (with RN A's arm around Patient #2's neck).
- Patient # 6, Staff O, and Staff P were identified as being present during the incident.

III. Incident and Complaint/Grievance log review

Review of incident log revealed no evidence that the alleged physical abuse was reported on the day of the incident, 11/14/22.

Complaint/Grievance log review revealed:
- Licensed Practical Nurse (LPN) B reported the incident on 11/15/22 (1 day after incident) to Patient Advocate A. The incident was entered into the grievance/complaint log.
- Patient Advocate A viewed the video.
- Patient Advocate A spoke with Patient #2, and told her that she could call the police.

IV. Staff Interview

Interview with Director of Risk/Performance Improvement (PI) A on 11/22/22 from 10:30 to 10:42 AM revealed:
- Patient Advocate A verbally notified the Director of Risk Management/PI on 11/15/22.
- Incident report was submitted by Patient Advocate A, in full, on 11/16/2022.
- Director of Risk Management/PI A notified the Department of Human Resources (HR) on 11/16/2022 at 2:00 PM, to have RN A removed from Unit D West pending investigation, but not to temporarily suspend RN A at that time as is hospital policy.
- Director of Risk Management/PI A viewed the video surveillance on 11/18/22 at approximately 4:00 PM. RN A was then suspended (4 days after the incident).
- Director of Risk Management/PI A confirmed that the police were not notified of the incident, and that Patient #2 was not evaluated medically for the incident. No witness statements by staff or patients were obtained.

V. Medical Record Review

Medical record review for Patient #2 revealed:
- Nursing Assessment Narrative Daily Progress Note on 11/14/22 for Night shift read, "No issues". This was signed by RN A at 6:30 AM.
- Nursing Assessment Narrative Daily Progress Note on 11/14/22 at 11:20 AM read, " ...Crying ...Peers indicated pt [patient] had been disruptive, and aggressive towards staff ..."
- Review of Practitioner Order Sheets from 11/14/22 to 11/21/22 revealed medical consults ordered:
a. 11/18/22 for possible urinary tract infection
b. 11/19/22 for gastrointestinal upset
No evidence of medical consult ordered for alleged assault by RN A.
- Nursing Assessment notes were charted by RN A on the following dates:
a. 11/14/2022 (date of incident)
b. 11/15/2022
c. 11/16/2022
d.11/17/2022
e. 11/18/2022
- DON A confirmed this finding on 11/22/22 at 2:20 PM, and stated that RN A was scheduled on a different unit than D West, and must have been moved back to D West. Also stated that communication regarding suspended or transferred staff is done verbally by HR to Nursing Supervisors who are responsible for making the schedules. Nursing Supervisors then pass this information along in shift report.

VI. Immediate Jeopardy

The facility failed to immediately report, investigate, and suspend RN A pending investigation of allegation of physical abuse.

As a result of this failure, Immediate Jeopardy (IJ) was identified, and the facility was notified on November 22, 2022, at 2:25 PM. The facility submitted and implemented an acceptable plan to remove the IJ, that was verified on site by the State Survey Agency on November 28, 2022, at 1:35 PM.

The following interventions were implemented to resolve the IJ:
- Re-education of all hospital staff on abuse, neglect, and exploitation
- Education to all staff regarding reporting allegations of abuse, completing incident reports, increased supervision by Nursing Coordinators, new protocol for suspension of staff pending investigations regarding allegations of abuse utilizing electronic scheduling software, and training for hospital leaders regarding significant event management.
- Education was completed by all staff members prior to beginning their next scheduled shifts.
- State surveyors verified training, and reviewed attestations and testing completed by staff.

Staff were interviewed on November 28, 2022, and able to verbalize understanding of education received.

Based on hospital policy review, document review, medical record review, and staff interview, it was determined the hospital failed to provide services and honor patient rights of transfer and discharge against medical advice (AMA) for one (Patient #1) of five patient medical records sampled. Findings include:

I. Policy review

Hospital policy titled "Discharge Process Policy" stated, "...All patients, regardless of discharge type, complete aftercare plan that includes...aftercare appointments for psychiatric and medical needs, prescriptions for medications, and a crisis safety plan...discharge instructions for medications and access to community resources..."

Hospital policy titled "Discharge Against Medical Advice (AMA Discharge)" stated, "...Nursing staff endeavors to allay anxieties and discuss the benefits of completing treatment and carrying out a planned discharge...If the patient or family insists on leaving, they are informed...the patient must provide written notice of their intention to leave program..."


II. Medical Record review for Patient #1

Patient #1 was admitted on 11/3/22 at 9:08 AM with a chief complaint of "Suicidal and Outbursts". Patient #1 was discharged against medical advice (AMA) on 11/7/22 at 3:51 PM.

Review of Patient #1's Discharge Care Plan and Home Medications dated 11/7/22 at 3:20 PM revealed:
- "Scheduled Aftercare Appointments" lacking evidence of outpatient follow-up appointments. "AMA discharge" written in this section.
- "Discharge Plan Review" section was not completed. No documentation that "Questions about my discharge plan have been answered", "Problems that I need to watch for have been reviewed with me", and "I have a copy of my Crisis Safety Plan" were reviewed with Patient #1 or patient guardian.
- "Current Medications" section not completed. Instead, "Pt [patient] d/c [discharge] AMA" written in this section. No evidence that information regarding Patient #1's medications received during hospitalization was communicated to patient or patient guardian.

Review of Patient #1's "Nursing Discharge Note" revealed:
- No copy of Discharge Instruction Plan was given to and reviewed with the patient or family, with the explanation given as "AMA".
- No Medication Prescriptions and education given to the patient or family, with the explanation given as "AMA".
- For the question, "Did the patient, family, guardian or POA state that he/she understands his or her health condition, what symptoms/problems to watch out for, and how to access mental health care assistance for exacerbation of symptoms?", the answer documented was "No", with the explanation as "AMA".
- For the question, "Did the patient, family, guardian or POA state an understanding and knowledge about the drugs that have been prescribed for what conditions, including how and when to take them?", the answer documented was "No", with the explanation as "AMA".

Review of Patient #1's "Progress Notes" revealed:
- Documentation on 11/7/22 at 3:30 PM stated, "...Pt [patient] verbalized fleeting thoughts of SI [suicidal ideation] to the Dr [doctor] today and told the nurse on d/c [discharge] he had thoughts to harm self..."

No evidence that Patient #1 or the patient's family was provided with discharge instructions, aftercare follow-up, prescriptions for medications received during hospitalization, or a crisis safety plan at time of discharge against medical advice. No evidence of written notice of a request for discharge, per hospital policy, in the medical record. During an interview on 11/28/22 from 10:20-10:25 AM with Director of Clinical Services (DCS) A and Director of Quality A, these finding were confirmed. Further, DCS A stated he/she was unaware that discharge instructions should be completed for discharges against medical advice.