HospitalInspections.org

Based on review of documentation and interview it was determined that the hospital failed to ensure that patient rights were respected as a towel was placed over the face of a patient.

Findings were:
On 9/20/2018 hospital staff members placed a towel over the face of patient #1 while moving him into a hospital bed. Patient #1 was documented (per hospital discharge summary) as having a long and complex medical history for profound intellectual disabilities, developmental deficits, Autism Spectrum Disorders, ADHD, Bipolar 1 disorder, physical aggressive behavioral, scoliosis, chronic constipation, vitamin D deficiency and Neuroleptic-induced Parkinsonism.

Review of an Electronic incident report (dated 9/20/2018 at 9:30am) which was shown to the surveyor stated: "(name of patient # 1) was in the floor on his mat with pillow and mittens on untied. Scheduled medications were on board. Sitter, (name of staff member here) states that the patient began kicking and spitting, and hitting (name of staff member) once he began to help him. Towel was placed over face and patient was held until help arrived. He was placed in the bed by staff, (names of staff members here). Then bilateral wrist restraints placed and mittens adjusted. No additional meds were given. (Name of staff member here) notified and (name of staff member here) notified. Will place a call to family member to either Mom or Dad in AM. Towel removed from face once calm in bed and wrist restraints released within an hours' time. Patient was held for total of 5 minutes. Ice applied to left ankle for redness and possible small amount of swelling. (Name of staff member here) informed of ice application and current assessment of left ankle."

Review of hospital CPI & Aggressive Behavior Class 101 Outline revealed that on page 7 of this handout there was a section entitled: Spitting. Comments related to this area stated: "Try to avoid giving resident any reaction and turn away head away if possible. Staff can hold up a pillow between resident who is doing the spitting and the staff member. NEVER PLACE ANYTHING OVER OR IN RESIDENT'S MOUTH."

Review of hospital policy and Procedure entitled: "Patient Bill of Rights" contained the comment: "This policy is intended to inform patients, families, and all staff of the Bill of Rights upheld by Nexus Children's Hospital." On page two of the policy, there were multiple statements regarding patient rights listed under the heading: "DIGNITY AND RESPECT" Among the statements was: "An environment that preserves dignity and contributes to a positive self-image."

In an interview conducted with staff members #1 and #2 on the morning of 2/26/2019 it was confirmed that placing a towel over the face of a patient was not an approved therapeutic intervention to be used by the hospital. In an interview with staff member #3 on the early afternoon of 2/26/2019 it was again confirmed that placing a towel over the face of a patient was not an approved therapeutic intervention to be used by the hospital.