HospitalInspections.org

A. Based on record review, observation and interviews, it was determined the hospital failed to protect patients from potential harm in one (1) of sixteen (16) patients reviewed (Patient #1), by failing to supervise staff, by allowing one-to-one staff to patient assignments, by failing to maintain control of keys to locked rooms, by failing to prevent access to chemicals by patients and by failing to document disciplinary actions toward staff following reports of inappropriate behavior. This created an environment in which abuse of staff toward patients could go unrecognized and unreported, patients can come into contact with harmful chemicals, and has the potential to affect the safety and well-being of all patients in this facility.

Findings include:

1. Facility policy entitled "Progressive Disciplinary Action", last revised 8/15/07 was reviewed. It states, in part, under the heading "A. Verbal Reprimand - The first level of disciplinary action taken against an employee for a relatively minor infraction of conduct policy, procedure, or other incident is a well documented verbal reprimand. It is documented on Human Resources For #HH-327-91, 'Documentation of a Verbal Reprimand' and remains in an employee's administrative file in the supervisors's office for one year."

2. An interview was conducted with the Interim Director of Adjunctive Therapy on 7/2/13 at 0900. He reported recalling counseling the staff member named in the complaint allegation, AT #1, following a report of inappropriate behavior. He stated he did not document this counseling session in any way. He stated that he was aware of an active investigation by Adult Protective Services (APS) in "early 2013" involving AT #1 and Patient #1, but did not change or increase supervision of this employee during that time. He stated that AT #1 worked every weekend, and that there are no Adjunctive Therapy supervisors in the facility on weekends.

3. An interview was conducted with the Director of Psychology. He stated he is in charge of the Adjunctive Therapy Department as well as other departments of the facility, and also sees Patient #1 for therapy. He reported taking Patient #1's statement in which he reported the alleged abuse by AT #1. He stated that he did not document this in the patient's medical record, nor did he complete and Incident Report about this. He stated he was unaware that an Incident Report needed to be completed. He stated there are no Adjunctive Therapy supervisors at the facility on weekends.

4. An interview was conducted with the Coordinator of Vocational Training and a review was made with her of the Adjunctive Therapy Department Charge Logs. She stated many of the log sheets are missing due to her inadvertently shredding them recently. She stated the log sheets indicate the names of the patients working on each day, the number of hours of work completed, and the staff assigned to attend them. She agreed there are numerous instances of staff and patients working one-to-one on the log sheets. She stated there are no Adjunctive Therapy supervisors in the facility on weekends.

5. An interview was conducted with HSW #1 on 7/3/13 at 0915. She reported that, on multiple occasions AT #1 arrived on Unit 2 and stated "I'm taking (Patient #1) off the floor for a while." She stated this often occurred on Saturdays and that Unit 2 staff noticed Patient #1 gone for "hours, like all day". She stated that, at that time, there was no system in place for Unit 2 staff to know where Patient #1 was being taken, what work had been assigned, and how long he was expected to be absent from the unit.

6. Observations were made during a tour of the Adjunctive Therapy Building #5 in the company of the Interim Director of Adjunctive Therapy. Numerous classrooms and storage closets were noted to be unlocked, including one storage room which was noted by the Interim Director to contain "chemicals used by Housekeeping". The Interim Director also stated that patients are routinely transported past these unlocked areas and could easily gain access to them. The Interim Director was unable to locate a key to the apartment in the basement which had been named in the complaint and was unable to determine the location of this key. He looked for the key in the Adjunctive Therapy office and found several other keys missing from their key tags in the "key box", namely keys for the Beauty Shop, the Library, a storage room and a key he named as "outside Rec. Hall door". He stated the Adjunctive Therapy staff carry their own set of keys and that the missing keys are considered "spare keys". He stated the Adjunctive Therapy secretary checks the keys in the box "once in a while". He was unable to determine the location of any of the missing keys.