HospitalInspections.org

Based on video review, document review, record review and staff interview it was determined the facility failed to provide care in a safe setting, provide the patient personal privacy, keep the patient free from abuse and follow their abuse and complaint/grievance policies for one (1) of thirty (30) patients (patient #1). The failure to provide care in a safe setting, keep the patient free from abuse and follow facility policies and procedures has the potential to affect all patients (See Tags A 122, A 143, A 144, A 145).

Findings include:

A. An Immediate Jeopardy (IJ) to Patient Rights (care in a safe setting, provide the patient personal privacy, keep the patient free from abuse, follow their abuse policy and follow their complaint/grievance policy) was called on 3/30/21 at 3:53 p.m. as policies and procedures were not followed by staff after a patient was struck in the head by a security guard.

B. Harm or Potential Harm: The security guard was not removed from staffing immediately as dictated by policy. He continued to work the rest of his shift.

C. Immediacy: All staff on the unit who had knowledge of the abuse did not receive training after the incident. Interviews with the Licensed Practical Nurse on 3/30/21 at approximately 3:20 p.m. and Behavioral Health Technician #3 on 3/30/21 at approximately 3:40 p.m. revealed they had not witnessed the abuse but had been told about it from other staff members. They did not question the Clinical Manager about the security guard still working after the incident.

D. An immediate plan of correction was received and sent to the State Agency Program Manager. It was accepted and the IJ was abated at 5:38 p.m.

Based on document review and staff interview it was determined the facility did not follow their complaint/grievance policy for one (1) of thirty (30) patients who had a grievance of abuse (patient #1). This failure has the potential to affect all patients who have a complaint or grievance.

Findings include:

1. A review of the facility policy entitled 'Patient Complaint and Grievances,' last revision date 10/21/19, revealed in part: "Grievance means an oral or written complaint that is not immediately resolved at the time of the complaint by staff present. A grievance may be made by the patient or the patient's representative, but not limited to the following: Abuse or neglect ... The grievance and problem resolution should be documented ... The patient shall be given a copy of the complaint, as requested, and final decision and a copy shall be filed in the complaint/grievance log."

2. A review of the facility document entitled 'Grievance Log,' dated 10/7/20 to 3/21/21, revealed there was no documentation of the grievance of abuse reported by patient #1.

3. An interview was conducted with the Chief Quality Officer on 3/30/21 at approximately 11:00 a.m. and she concurred with the above findings.

Based on document review, record review and staff interview it was determined the facility failed to provide one (1) of thirty (30) patients personal privacy by denying lower body clothing because of repeated soiling of the clothing (patient #1). This failure to provide clothing has the potential to cause psychological and physical harm to every patient who has soiled clothing.

Findings include:

1. A review of the facility policy entitled 'Patient Rights and Responsibilities,' not dated, revealed in part: "To be free from all abuse and harassment. To be treated with consideration, respect and recognition of their individuality, including the need for privacy in treatment."

2. A review of the facility policy entitled "Privacy," dated 7/17/18, revealed in part: "It is the policy of Highland-Clarksburg Hospital to enforce measures that support all patient's right to privacy. Restrictions, which may impact on privacy, are utilized only to protect patient safety and well-being and only with a written physician's order that includes the clinical justification for such restriction."

3. A medical record review of the physician orders revealed there was no order to restrict clothing for patient #1.

4. An interview conducted on 3/30/21 at approximately 9:00 a.m. with Behavioral Health Technician (BHT) #1 revealed patient #1 was wearing a shirt and blanket around his shoulders and was "naked from the waist down."

5. An interview conducted on 3/30/21 at approximately 10:00 a.m. with BHT #2 revealed patient #1 had been urinating in his room and clothes. He wanted new clothes, but the day shift would not give him the clothes. She said the day shift reported to the night shift he was doing it on purpose and not to give him any clothes either. She stated there was no doctor's order for not giving patient #1 pants. She also stated, "stuff like not getting pants didn't just happen to [patient #1] it happens to a lot of people."

4. An interview was conducted with the Chief Quality Officer on 3/30/21 at approximately 11:00 a.m. and she concurred with the above findings.

Based on video review, document review and staff interview it was revealed the facility failed to provide care in a safe setting for one (1) of thirty (30) patients who was abused by a staff member (patient #1). The staff member was not immediately removed from staffing and the abuse policy and procedure was not followed. The failure to provide care in a safe setting has the potential to adversely affect all patients.

Findings include:

1. On 3/29/21 at approximately 9:00 a.m. a review of a video of the 5 North hallway dated 3/18/21 at approximately 7:40 p.m. was completed. The security guard was noted to be in the hallway outside of patient #1's room. The patient came out of the room and was seen saying something to the security guard. The security guard shoved the patient to the wall and hit him on the right side of the head.

2. A review of the facility policy entitled 'Abuse and Neglect Procedure,' last revision date 1/28/16, revealed in part: "Abuse means the intentional infliction or threat to inflict physical pain or injury or the imprisonment of any incapacitated adult or facility resident ... Appropriate measures will be taken upon any disclosure of abuse and/or neglect by a patient to provide for safety, supervision and protection of the identified patient and all other patients ... if the allegations are against a staff member, the individual will be removed from all patient care areas until an investigation can be completed and the incident reported as necessary ... All suspected and reported cases of abuse or neglect of patients will be reported immediately to both Quality Assurance (QA) or designee and the Director of Therapy and Social Services or designee in order for necessary steps of investigation and determination of the need for external reporting to occur within required timeframes."

3. A review of the facility flow diagram entitled 'Staff to Patient Abuse Process,' revision date 2/25/16, revealed in part: "Remove staff from all patient care areas ... Start Incident Report Process ... After office hours-Notify House Supervisor who will notify AOC [Administrator on Call] ... AOC will obtain statements after hours."

4. A review of an email dated 3/19/21 at 7:34 a.m. revealed night shift Clinical Manager #1 notified nursing leadership and the Chief Quality Officer of the alleged abuse the next morning. There is no documentation the Administrator on call was notified at the time of the incident.

5. A telephone interview with Clinical Manager #2 was conducted on 3/30/21 at approximately 8:30 a.m. She stated she walked to the seclusion room with patient #1. He went willingly and said, 'what are you going to do about him-he hit me' (meaning the guard). She stated, "No one had said anything to us except [patient #1] that anything was any different. [Patient #1] had said before that people had hit him."

6. A telephone interview with Behavioral Health Technician (BHT) #1 was conducted on 3/30/21 at approximately 9:00 a.m. She said patient #1 was throwing urine on the wall and staff. The security guard held patient #1 back so he would not come out in the hall. Patient #1 was hitting the security guard in the stomach and she saw the security guard swing at patient #1. She stated she was "pretty sure he hit him in the face." She said patient #1 was telling everyone the security guard hit him. She also stated, "One of the Clinical Managers said they would review the cameras, but everyone knew at this point he hit him."

7. A telephone interview with BHT #2 was conducted on 3/30/21 at approximately 10:00 a.m. She said patient #1 started hitting the security guard in the stomach and chest and she saw the security guard lift his left arm up and she knew that was not "CPI" (Crisis Prevention Institute). She also stated that later in the shift at approximately 9:00 p.m. patient #1 had a code gray called and returned to the seclusion room. She accompanied the patient along with the licensed practical nurse and the security guard.

8. A telephone interview with BHT #3 was conducted on 3/301/31 at approximately 3:35 p.m. He said he did not witness the incident but was with patient #1 when he went to the seclusion room for a "time out". He said the security guard was outside the door of the seclusion room.

9. An interview was conducted with the Chief Quality Officer on 3/30/21 at approximately 11:00 a.m. and she concurred with the above findings.

Based on video review, document review, record review and staff interview it was determined the facility failed to keep the patient free from all forms of abuse for one (1) of thirty (30) patients by removing a security guard from staffing who had struck the patient and denying the patient clothing (patient #1). The failure to keep patients free from abuse has the potential to adversely affect all patients.

Findings include:

1. On 3/29/21 at approximately 9:00 a.m. a review of a video of the 5 North hallway dated 3/18/21 at approximately 7:40 p.m. was completed. The security guard was noted to be in the hallway outside of patient #1's room. The patient came out of the room and was seen saying something to the security guard. The security guard shoved the patient to the wall and hit him on the right side of the head.

2. A review of the facility policy entitled 'Abuse and Neglect Procedure,' last revision date 1/28/16, revealed in part: "Abuse means the intentional infliction or threat to inflict physical pain or injury or the imprisonment of any incapacitated adult or facility resident ... Appropriate measures will be taken upon any disclosure of abuse and/or neglect by a patient to provide for safety, supervision and protection of the identified patient and all other patients ... if the allegations are against a staff member, the individual will be removed from all patient care areas until an investigation can be completed and the incident reported as necessary ... All suspected and reported cases of abuse or neglect of patients will be reported immediately to both Quality Assurance (QA) or designee and the Director of Therapy and Social Services or designee in order for necessary steps of investigation and determination of the need for external reporting to occur within required timeframes."

3. A review of the facility flow diagram entitled 'Staff to Patient Abuse Process,' revision date 2/25/16, revealed in part: "Remove staff from all patient care areas ... Start Incident Report Process ... After office hours-Notify House Supervisor who will notify AOC [Administrator on Call] ... AOC will obtain statements after hours."

4. A review of the facility policy entitled 'Patient Rights and Responsibilities," not dated, revealed in part: "To be free from all abuse and harassment. To be treated with consideration, respect and recognition of their individuality, including the need for privacy in treatment."

5. A review of the facility policy entitled "Privacy," dated 7/17/18, revealed in part: "It is the policy of Highland-Clarksburg Hospital to enforce measures that support all patient's right to privacy. Restrictions, which may impact on privacy, are utilized only to protect patient safety and well-being and only with a written physician's order that includes the clinical justification for such restriction."

6. A review of an email dated 3/19/21 at 7:34 a.m. revealed the night shift Clinical Manager #1 notified nursing leadership and the Chief Quality Officer of the alleged abuse the next morning. There is no documentation the Administrator on call was notified at the time of the incident.

7. A medical record review of the physician orders revealed there was no order to restrict clothing for patient #1.

8. A telephone interview with Clinical Manager #2 was conducted on 3/30/21 at approximately 8:30 a.m. She stated she walked to the seclusion room with patient #1. He went willingly and said, 'what are you going to do about him-he hit me' (meaning the guard). She stated, "No one had said anything to us except [patient #1] that anything was any different. [Patient #1] had said before that people had hit him."

9. A telephone interview with Behavioral Health Technician (BHT) #1 was conducted on 3/30/21 at approximately 9:00 a.m. She said patient #1 was throwing urine on the wall and staff. The security guard held patient #1 back so he would not come out in the hall. Patient #1 was hitting the security guard in the stomach and she saw the security guard swing at patient #1. She stated she was "pretty sure he hit him in the face." She said patient #1 was telling everyone the security guard hit him. She also stated, "One of the Clinical Managers said they would review the cameras, but everyone knew at this point he hit him."

10. A telephone interview with BHT #2 was conducted on 3/30/21 at approximately 10:00 a.m. She said patient #1 started hitting the security guard in the stomach and chest and she saw the security guard lift his left arm up and she knew that was not "CPI" (Crisis Prevention Institute). She also stated that later in the shift at approximately 9:00 p.m. patient #1 had a code gray called and returned to the seclusion room. She accompanied the patient along with the licensed practical nurse and the security guard.

11. A telephone interview with BHT #3 was conducted on 3/301/31 at approximately 3:35 p.m. He said he did not witness the incident but was with patient #1 when he went to the seclusion room for a "time out". He said the security guard was outside the door of the seclusion room.

12. An interview conducted on 3/30/21 at approximately 9:00 a.m. with BHT #1 revealed patient #1 was wearing a shirt and blanket around his shoulders and was "naked from the waist down."

13. An interview conducted on 3/30/21 at approximately 10:00 a.m. with BHT #2 revealed patient #1 had been urinating in his room and clothes. He wanted new clothes, but the day shift would not give him the clothes. She said the day shift reported to the night shift he was doing it on purpose and not to give him any clothes either. She stated there was no doctor's order for not giving patient #1 pants. She also stated, "stuff like not getting pants didn't just happen to [patient #1] it happens to a lot of people."

14. An interview was conducted with the Chief Quality Officer on 3/30/21 at approximately 11:00 a.m. and she concurred with the above findings.

Based on document review, record review and staff interview it was determined for one (1) of thirty (30) patients nursing did not follow the facility policies and procedures and notify the physician the patient said he had been abused (patient #1). This failure has the potential to adversely affect all patients.

Findings include:

1. A review of the facility policy entitled 'Abuse and Neglect Policy,' last revision date 1/28/16, revealed in part: "Nursing and medical staff shall attend to any basic medical/first aid needs of the patient."

2. A review of the medical record for patient #1 dated 3/19/21 at 7:24 a.m. revealed an entry for "1945 Dr. [physician name] notified of [Patient #1's] behavior, order received for Vistaril 25 mg IM x one. [Patient #1] walked to the seclusion room and stood for fifteen minutes." There is no documentation the physician was notified patient #1 had stated he had been abused.

3. A telephone interview conducted with Registered Nurse #1 on 3/30/21 at approximately 9:30 a.m. revealed patient #1 was slamming the door and she stated, "I stopped it with my hand. I heard [patient #1] say he hit me. I didn't see [security guard] do anything." She also stated she thinks she told the physician patient #1 "says we were hitting him, and no one was hitting him."

4. An interview was conducted with the Chief Quality Officer on 3/30/21 at approximately 11:00 a.m. and she concurred with the above findings.