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A. Based on record review and interviews, it was determined that for 1 of 1 (Pt.1) clinical records reviewed of patients with alleged abuse, the Hospital failed to ensure the patient was free from physical and verbal abuse, thus placing the 23 patients on the Psychiatric Unit on 8/21/12 at risk for patient rights violations. Refer to deficiencies at A145 A and A145 B. As a result, it was determined that the Condition of Patient Rights was not in compliance.

1. The Hospital failed to ensure the patient was free from both physical and mental abuse.
See deficiency at A145 A.

2. The Hospital failed to conduct a thorough investigation of the alleged incident. See deficiency at A145 B.

An Immediate Jeopardy (IJ) and serious threat to patients' safety and wellbeing was created from the cumulative effects of these systematic practices.

The Hospital's Chief Operating Officer, Chief Nursing Officer and Psychiatric Unit Director were notified on 10/24/12 at 9:20 AM that an an Immediate Jeopardy (IJ) exists. The IJ identified was the Hospital's failure to ensure Pt. #1 was free from physical and mental abuse by staff. In addition, the Hospital failed to implement corrective actions to prevent reoccurrence of the deficient practice.

As of survey date 10/24/12, the Hospital has no corrective action in place to remove the IJ as the Mental Health Counselor (E #3) identified as having thrown Pt #1 to the floor, was still working and not removed from patient care. Further, there has been no staff re-education, counseling or training in regards to proper patient behavioral intervientions and mental abuse. Therefore, the IJ remains in effect.

A. Based on record review and interviews, it was determined that for 1 of 1 (Pt #1) clinical record reviewed of a patient with alleged abuse, the Hospital failed to ensure the patient was free from both physical and mental abuse. Findings include:

1. On 10/18/12 at approximately 10:30 AM, the clinical record for Pt. #1 was reviewed. Pt. #1, a 22 year old male, was admitted to the 6th floor psychiatric unit on 8/17/12 from the emergency department for increasingly aggressive behavior at home. At the time of admission, Pt. #1 was anxious and hearing voices. Pt. #1 was listed as alert, oriented, cooperative but agitated. Pt. #1's diagnoses as documented by MD#1 were Schizoaffective disorder versus Bipolar disorder.

2. Hospital policy entitled, "Rights and Responsibilities of Patients," (reviewed/updated 6/2011) required, "...Safety. The patient has the right to expect reasonable safety insofar as the hospital practices and environment are concerned. The patient has the right to be protected from neglect...and abuse that could occur while receiving care..."

3. Hospital policy entitled, "Rights and Responsibilities of Patients," (reviewed/updated 6/2011) required, "...Respect and Dignity. The patient has the right to considerate and respectful care at all times and under all circumstances..."

4. On 10/18/12, the Hospital presented an internal investigation timeline regarding the alleged occurrence on 8/21/12. The document included that, "Mental Health Counselor believed that the RN and Unit Secretary were toying inappropriately with the patient as he was making sexually inappropriate comments to them for over an hour..."

5. The Psychiatric Unit Director (E #4) was interviewed on 10/18/12 at approximately 8:50 AM. During the interview E #4 stated that E#1 reported to the Unit Director on 8/31/12 (10 days later) that he saw E#3 choke Pt. #1 while attempting to get Pt.#1 into the quiet room on 8/21/12 and that E#6 stated that E#3 used unnecessary force but denied that E#3 choked Pt. #1.

During the interview, E #4 stated that during staff interviews regarding the alleged incident, Unit staff voiced their concerns that E #1 may have been "toying with the Pt." as the patient was making sexually inappropriate comments to them (staff) for over one hour. E #4 also stated that MHC's (E #3) perception was that E #3 was aggravating Pt #1 which lead to Pt #1 threatening E #3.

6. E#6 (Unit Secretary) was interviewed by telephone on 10/19/12 at approximately 1:35 PM. E#6 stated that he witnessed E#3 throw Pt. #1 on the floor. E#6 stated, "while E#3 was coming down the hall, I heard the Pt. say what's up? E#3 throw the Pt. to the floor."

7. The Director of the Psychiatric Unit was made aware of the findings during an interview on 10/24/12 at approximately 9:00 AM.


B. Based on record review, interviews and video review, it was determined that for 1 of 1 (Pt.1) clinical records of patients with a documented fall during restraint application, it was determined that the Hospital failed to conduct a thorough investigation of the alleged incident.
Findings include

1. On 10/18/12 at approximately 10:30 AM, the clinical record for Pt. #1 was reviewed. Pt. #1, a 22 year old male, was admitted to the 6th floor Psychiatric unit on 8/17/12 from the Emergency Department for increasing aggressive behavior at home. At the time of admission Pt. #1 was anxious and hearing voices. Admission orders dated, 8/17/12 included close observation (CO). The psychiatric evaluation by MD #1 dated, 8/17/12, included information that Pt. #1 was angry with his mother and was hitting the garage door with his open hands. Pt. #1 admitted to hearing voices but denied suicidal or homicidal ideation. Pt. #1 was listed as alert, oriented, cooperative, but agitated. Pt. #1's diagnoses as documented by the MD#1 were Schizoaffective Disorder verses Bipolar Disorder. Registered Nurse (RN) (E#2) documentation dated 8/21/12 at 9:30 PM included, "Pt. was seen inappropriate with staff, ... making obscene gestures, disrobing in the hall. Became aggressive when redirected. Posturing. Given PRN and put in 4 point locked restraints." The clinical record contained an order for the restraints dated 8/21/12, a restriction of rights and a face to face assessment within 1 hr. Increased monitoring included 1:1 observation, assault and sexual acting out precautions, which were completed as required every 15 minutes. Pt. #1 was in restraints from 8/21/12 at 9:30 PM until 8/21/12 at 11:45 PM.

2. A video was viewed on 10/18/12 at 2:20 PM. At 9:24 PM on 8/21/12, RN E#1, and RN (E# 5), and Unit Secretary (E#6) are standing in the west hallway. Pt. #1 meets a Mental Health Counselor (MHC) (E#3) at the intersection of the east and west hall. E#3 approaches Pt. #1 and then they go off camera. Approximately 1 ? seconds later, Pt. #1 and E#3 are observed on the floor. E #1 and E#6 are standing looking at both Pt #1 and E#3 and offering no assistance. At 9:25 PM, another MHC (E#7) enters and walks Pt. #1 to the quiet room with E#1 following. There was no resistance by Pt. #1 and no physical touch upon being walked to the quiet room. There was no documentation on an occurrence report or in the clinical record that Pt. #1 ended up on the floor or was examined for any injuries.

3. Hospital policy titled, " Confidential Occurrence/ Investigation Reports" review date 2/2012 was reviewed on 10/19/12 at approximately 2:20 PM. The policy included, " An occurrence may be defined as a patient event which is not under ordinary circumstances, expected in the course of, or as a consequence of hospital/medical treatment...the identification of such an event only indicates the potential need for further investigation...An occurrence report should be completed on line for the Quality Improvement Department within twenty four (24) hours of the occurrence /event or its discovery".

4. The Psychiatric Unit Director (E #4) was interviewed on 10/18/12. E #4 stated that E#1 reported to the Unit Director on 8/31/12 (10 days later) that he saw E#3 choke Pt. #1 while attempting to get Pt.#1 into the quiet room on 8/21/12 and that E#6 stated that E#3 used unnecessary force but denied that E#3 choked the Pt.

5. E#6 was interviewed by telephone on 10/19/12 at approximately 1:35 PM. E#6 stated that he witnessed E#3 throw Pt. #1 on the floor. E#3 stated, "while E#3 was coming down the hall, I heard the Pt. say what's up? E#3 throw the Pt. to the floor."

6. As of survey date 10/24/12, there had not been a thorough investigation regarding the alleged incident of Pt #1 and E #3 ending up on the floor. E#3 continued to be employed and was not removed from patient care.

7. The Director of the Psychiatric Unit stated during an interview on 10/19/12 that the alleged incident had not been reported for 10 days and that an occurrence report or thorough investigation had not been completed.