HospitalInspections.org

Based on document review, interview, and policy review the facility failed to keep patients free from physical abuse and harassment with one (pt.#2) of twenty-one patients resulting in physical abuse of a patient. Findings include:

1. Failure to protect and report the physical abuse of a patient. (See tag A-145)

Based on document review, interview, and policy review the facility failed to keep patients free from physical abuse and harassment with one (#2) of twenty-one patients resulting in physical abuse of a patient. Findings include:

On 12/27/2018 at approximately 1245 the medical record of patient #2 was reviewed and revealed patient #2 was a 78-year-old female who entered the facility as a surgical patient for thoracic T6 - T12 posterior instrumented fusion of the spine and hardware removal. The patient's history included compression fracture of thoracic vertebrae T9-T10, congestive heart failure, pulmonary embolism, atelectasis, displacement of internal fixation device of vertebra, hypertension (high blood pressure), spondylosis (thoracic region), spinal stenosis lumbar region, hypothyroidism, hyperparathyroidism, hyperlipidemia, and migraines. Further medical history included persistent asthma, gastro-esophageal reflux disease, lung cancer, breast cancer, transient ischemic attack (mini stroke), right hip replacement, right knee replacement, and osteoarthritis of the spine. The patient underwent surgery on 12/7/2018 and was discharged to a skilled assisted rehabilitation center for 10 -14 days of rehabilitation therapy.

According to the physical therapy assistant's note (staff X) on 12/9/2018 at 1059 the patient rated her pain as 10/10 and stated, "I'm just not going to do it today." The patient's mood was documented as, "agitated; angry; combative (aggressive); hostile; threatening." The patient was also documented as having decreased use of arms and decreased use of legs. Pain was documented as an impairment."

Further documentation on 12/9/2018 at 1211 by the occupational therapist assistant (staff S) stated the following, "Tolerated session poorly. Initially stated did not want to participate with therapy. Then she agreed to at least sit up and go to the bathroom. Patient sat EOB (edge of bed) with moderate assist, 2nd (standby staff present) for safety. Once EOB therapist had patient get her bearings and attempted to assist getting brace on to assist with support and pain. Patient resistive to therapists as therapist had to lift one hand up for the bed at a time to put the "sleeves" of the brace on. Verbally reviewed that the brace will help support back pain and to not resist. Patient then attempting to bite staff member. OT (occupational therapist) stated that was inappropriate behavior. Patient then slapped OT across the face. In defense slapped patient left shoulder stating "no, that is naughty, you don't slap people." Patient continued to be verbally aggressive yelling. RN (registered nurse) came in to calm patient down. This writer then left the situation. Recommend patient be seen with security services present. Recommend SAR (subacute rehab) at d/c."

On 12/28/2018 at 0900 staff T, a patient care manager was interviewed. Staff T was asked if she was aware of any allegations of patient abuse in the facility. Staff T responded, "I was contacted by a potential receiving subacute rehab(ilation) center about something they had found in notes that were sent for review in order to accept a patient for rehab." Staff T was then asked to explain. Staff T explained that in an Occupational Therapist Assistant's (OTA) documentation that the note stated the OTA had slapped a patient. Staff T was then asked what she did with this information. Staff T stated she had informed her manager and she had filed an incident report. Staff ** was asked if she had any further information to share. Staff T stated that the potential receiving facility had told her that the incident would have to be reported to the state agency.

On 12/28/2018 at 0930 an interview occurred with staff X, the Physical Therapy Assistant (PTA) who was present at the time of the incident between the patient and the OTA. Staff X was queried if the patient slapped the OTA. Staff X responded, "yes ...the patient became very agitated and slapped staff S, the OTA ...the OTA tapped the patient on the shoulder and told her that she wasn't to do that, and it was naughty to slap someone in the face." Staff X then was asked was the OTA loud when she corrected the woman. Staff X stated, "yes ...she was loud like a mother would be when mad with a child." Staff X was then asked if she was aware the OTA documented that she "slapped" the patient. Staff ** stated, "no."

An interview occurred on 12/28/2018 at 1045 with staff S, the OTA involved in the incident. Staff S was asked to explain the events of the occurrence with patient #2. Staff S stated that when she entered the patient's room that the patient initially refused therapy. She stated that she was encouraging the patient and although the patient was resistant to participating with therapy. Staff S further stated that the back brace being used for the patient was new to her and was difficult to put on. Staff S was asked how the physical therapist assistant became involved in the therapy session. Staff S stated, "We often coordinate therapy together in order to have another staff person present to assist." Staff S then was asked to detail the event. Staff S stated that once the patient was on the edge of the bed that applying the back brace was necessary in order for the patient to ambulate to the bathroom. Staff S reiterated that putting the back brace on was difficult and the patient lunged to bite her. Staff S was then asked why at the point where the patient lunged to bite her did the therapy session not end. Staff S stated, "I wanted to protect her dignity because she needed to urinate, and I didn't want her to urinate on the side of the bed." Staff S was then asked why nursing staff called to assist. Staff S stated the call light was not in reach for use. Staff S was then asked if the patient could have been returned to bed to use a bed pan. Staff S stated again the goal was for the patient to ambulate to the bathroom. Staff S stated the patient slapped her when she raised the patient's hand to put the brace on. Staff S stated that she "tapped" the patient on the shoulder and told her "No, we don't do that. It is naughty." Staff S was asked if she was aware that she had documented "slapped" and not "tapped." Staff S stated, "yes." Staff S was then asked if she thought the patient might have been in pain and by moving her arm that she had elicited a pain response first by her trying to bite and then by slapping. Staff S stated, "she had back surgery not arm surgery." Staff S was then asked if she was dealing with a patient with dementia and had that the same scenario and the same patient response occurred what her actions would be. Staff S stated, "She didn't have dementia." Staff S at the time of the interview failed to state a different approach or intervention that may have been used in the situation with the patient to result in a different outcome.

On 12/28/2018 at 1340 a review occurred of the policy titled, "Sexual and Physical Assault or other allegation of misconduct involving a patient-investigating allegation and notification," reference #1370, dated 07/27/2016. According to the policy the purpose is described as,"to assure that a thorough and impartial evaluation and investigation process is followed in the event of allegations of sexual misconduct, inappropriate physical contact or other misconduct in the course of patient care." Section 4.2 Investigation (4.2.2) "If applicable, the accused employee or provider will be immediately removed from the care of the patient making the allegation. If the employee is on-site, the decision is made to remove the individual from all job responsibilities, the employee will be requested to remain on-site in a private area accompanied by entity personnel until the patient has been interviewed."

On 12/28/2018 at 0820 an interview occurred with the Risk Manager, staff BB. Staff BB stated that looking back on the documentation that this incident had been viewed as workplace violence and not as patient abuse. Staff BB further added that this was an unusual case and that the person who had handled the incident failed to recognize that the employee responded physically with the patient. Staff BB stated the facility had failed to follow the policy and investigative process.