HospitalInspections.org

Based on interview, record review and review of the facility's policy, it was determined the facility failed to provide sufficient supervision and ensure protection of patients to prevent possible physical abuse for one (1) of eleven (11) sampled residents (Patient #1).

On 04/25/15, in the evening, Patient #11 exhibited aggressive behavior towards Patient #1, with immediate measures taken to protect Patient #1. However, the interventions implemented failed to prevent further aggressive physical behaviors by Patient #11 towards Patient #1, when the patients were permitted back in the same room the morning of 04/26/15. Patient #11 physically punched Patient #1 as the two (2) patients were permitted back in the same room together the following morning, 04/26/15.

The findings include:

Review of the facility's policies titled, "Reporting Adult Abuse", revised July 2013, and "Reporting Child Abuse", revised July 2013, revealed criteria for identifying "potential victims of abuse" included any report given by the patient that physical or sexual abuse had taken place.

Review of the facility's policy titled, "Behavior Management Program", revised May 2007, revealed the facility was "dedicated to providing a safe environment for its patients and staff". Per the Policy, the Behavior Management Program was developed as a "component" of the risk management program to minimize actual or potential injury through a "safe and effective approach toward management of aggressive or assaultive behaviors".

Review of the facility's policy titled, "High Risk Behavior Precautions", revised April 2014, revealed patients who exhibited high risk behaviors would be placed on appropriate precautions, with the patient's location and behavior documented. The Policy revealed its purpose was to establish guidelines for supervision of patients and interventions for patients who exhibited high risk behaviors. Continued review revealed early identifiers for patients who might require increased levels of supervision included, suicide/self harm, homicide/assault/aggression, medically compromised, victimization, falls, sexually acting out (SAO) or elopement. Per the Policy, all patients would be assessed for the following high risk behaviors: suicide/self harm, homicide/assault/aggression, medically compromised, victimization, falls, SAO or elopement. According to the Policy, homicide/assault/aggression was noted as a significant history of acts of aggression toward others, current acts of aggression towards others or verbal threats of violence towards others and aggressive acts resulting in deliberate destruction of property. Continued review revealed patients were reassessed throughout their hospitalization for any behavior or behavioral history which demonstrated a need for high risk precautions.

Review of Patient #1's medical record revealed the facility admitted the patient on 04/22/15, related to suicidal ideations and diagnoses which included Depressive Disorder, Anxiety State, and Episodic Alcohol Abuse. Review of the Interdisciplinary Master Treatment Plan for Patient #1 revealed the patient had a history of abuse, a history of abuse and victimization, and a history of treatment failure. Review of Patient #1's Individual Treatment Plan (ITP), dated 04/22/15, revealed a treatment plan for Depression with Suicidal Ideation with a "treatment modality" of fifteen (15) observations (obs) daily.

Review of Patient #11's medical record revealed the facility admitted the patient on 04/23/15, with suicidal ideation and also related to fighting at school, with diagnoses which included Depressive Disorder. Review of the Interdisciplinary Master Treatment Plan for Patient #11 revealed the patient had a history of victimization and a problem with cognitive functioning. Review of the Initial Nursing Treatment Plan dated 04/23/15, revealed problems for Patient #11 which included being a danger to self, self-injurious, danger to others and alteration in thought process. Review of the "specific intervention focus" revealed the interventions for danger to others included redirecting the patient from hostile, angry or threatening behavior and discuss appropriate alternatives to cope and to help the patient to identify triggers, warning signs and coping strategies for thoughts of harming others on the "patient safety plan". Continued review revealed the "treatment modality" for the danger to others problem was listed as 1:1 (one on one) with staff with the "frequency/duration" noted "as needed" and "upon admission". Review of the Progress Note dated 04/24/15, timed 11:00 PM, revealed after dinner, Patient #11 had an "aggressive outburst" during which the patient was attempting to attack staff, threw a water pitcher across the hallway, ripped papers and through the pieces in the hallway, "ripped out" patient's name tags above their room doors. Continued review of the 04/24/15, 11:00 PM, Note revealed Patient #11 was continuously cursing and kicking walls and doors.

Review of the facility's "Report of Suspected Abuse/Neglect", dated 04/25/15, timed 5:40 PM, documented by Registered Nurse (RN) #2, revealed Patient #11 and Patient #1 were "verbally arguing" and Patient #11 grabbed Patient #1 by the hair and hit Patient #1 in the head twice. Patient #1 was assessed by RN #2 with no injury noted and the patient stated he/she was okay. Further review revealed Patient #1 and Patient #11 were separated.

Interview with Lead Mental Health Technician (MHT) on 06/10/15 at 3:12 PM, revealed she was working the evening of 04/25/15 at 5:45 PM, when Patient #11 struck Patient #1. The Lead MHT revealed Patient #1 was arguing with another patient, Patient #11, in the dayroom, and then Patient #11 began moving towards Patient #1. Per interview, she separated Patient #11 from Patient #1 by taking him/her into the hallway, at which time Patient #11 got up and struck Patient #1 twice in the head.

Interview with RN #2 on 06/10/15 at 3:44 PM, revealed she did not witness the incident on 04/25/15; however, had heard "a code" called. Per interview, by the time she got to the dayroom, staff had separated Patient #1 and Patient #11. RN #2 revealed Patient #1 and Patient #11 remained separated for the rest of the night, as they were placed into two (2) different groups, and Patient #11 was in a room on a different hallway as well. Continued interview revealed there were no injuries to either patient as a result of Patient #11's aggressive behaviors. RN #2 revealed when she completed her shift she passed along in report to the following shift the information regarding what had occurred between Patient #11 and Patient #1 on 04/25/15.

Review of Patient #1's ITP revealed no documented evidence the patient's supervision was increased to protect him/her from further aggression and physical abuse by Patient #11.

Review of Patient #11's ITP revealed no documented evidence it was updated following the incident on 04/25/15, with increased supervision to prevent further aggression towards Patient #1 or other patients.

Interview and record review revealed neither Patient #1's or Patient #11's supervision level was increased after the incident on 04/25/15, to ensure protection of Patient #1 from further abuse by Patient #11. Additionally, even though both patients were assigned to separate groups, the facility's practice of having all patients meet in the dayroom each morning to process previous events and plan for the day ahead, placed Patient #1 at risk for further physical abuse by Patient #11.

Review of the facility's "Report of Suspected Abuse/Neglect", dated 04/26/15 timed 8:40 AM, documented by Mental Health Technician (MHT) #3, revealed Patient #1 was "sitting in the day room" when other patients "brought up" the previous incident on 04/25/15. Continued review revealed Patient #1 remarked "the attack against" him/her on 04/25/15 "didn't really hurt" and the patient stated he/she didn't really care what had happened previously. The Report revealed Patient #11 then "attacked" Patient #1 again, grabbing Patient #1's hair and punching Patient #1 in the face three (3) times. Further review revealed the patients were separated, the Physician, House Supervisor and patients' responsible parties were notified. In addition, the Report noted Patient #1 was assessed by a RN with "no apparent bruises or redness".

Interview with MHT #2 on 06/11/15 at 8:40 AM, revealed she worked from 7:00 AM until 11:00 AM on 04/26/15. She revealed that morning in report staff had been told Patient #11 had beaten up Patient #1 the night before, 04/25/15. Per interview, they were also told in report the plan was to keep the two (2) patients in separate groups to prevent further incidents. MHT #2 revealed for a brief few minutes the morning of 04/26/15, most of the adolescent patients were all in dayroom together, with staff and patients going over what had happened the night before and the plan for that day. Continued interview revealed in the brief five (5) minutes the patients and staff were in the dayroom, Patient #11 went up to Patient #1 and apologized, they shook hands, and Patient #11 went back across the room. According to MHT #2, about five (5) minutes later, however, unprovoked, Patient #11 walked very calmly over to Patient #1 and started hitting him/her in the face. MHT #2 revealed within seconds she and MHT #3 separated Patient #11, who went peacefully away with MHT #3. Per MHT #2, she stayed with Patient #1, and another staff member took all the other patients on to breakfast. MHT #2 revealed Patient #1 was shaken up and crying, as Patient #11 had pulled her hair, but she observed no injuries. Further interview revealed Patient #1 had stated "I just don't understand what I've done to" him/her (Patient #11) to make him/her "hate me so much". MHT #2 revealed Patient #1 had not provoked Patient #11 in any way, and Patient #11 was discharged from the facility shortly after the incident.

Interview with the Chief Nursing Officer (CNO) on 06/10/15 at 4:00 PM and 5:12 PM, and on 06/11/15 at 9:45 AM, revealed first thing in the morning adolescent patients go into the dayroom with staff present, to process the events of the previous day and make plans for the current day. The CNO revealed sometimes, with teenagers especially, they might only be separated from each other for a shift or two (2), depending on their behavior and how they were dealing with each other. Further interview revealed the CNO could not speak to the specifics of the situation with Patient #1 and Patient #11.