HospitalInspections.org

Based on interview, policy review and video recording review, the facility's governing body failed to:
- Provide a safe environment and prevent abuse and neglect of two discharged patients (#6 and #7) of two adult psychiatric patients in the Emergency Department (ED) when Patient #6 was neglected and not assessed after a fall and Patient #7 was physically and psychology abused by Staff W, Registered Nurse (RN);
- Ensure nursing staff followed the facility's policies regarding abuse and neglect by not immediately removing Staff W, RN from patient care after the allegation of abuse was reported;
- Recognize the staffs' fear of retaliation for reporting such abuse;
- Recognize the failure of the neglect of Patient #6 after she had fallen and was not immediately assessed;
These failures had the potential to affect the safety of all patients and had the potential for continued abuse and neglect and the failure of staff to intervene and/or report. The ED visits were 933 from 05/18/17 through 06/05/17. The facility census was 22.

Findings included:

1. Record review of the facility's policy titled, "Abuse/Neglect-Child/Disabled/Domestic/Elder and Patient Abuse," revised 06/2017, showed the directives that all patients in the facility will be protected from abuse by anyone including staff, other patients, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individual. If an employee is accused of abuse, the said employee will be immediately removed from clinical setting and/or duties.

Record review of the facility's policy titled, "Workplace Violence and Threats," revised 02/15/16 stated that
Management is responsible for fostering an environment that was safe and free from workplace violence. Retaliation and adverse treatment of an employee who had reported a concern or incident in good faith or who participated in an investigation are prohibited.

2. Record review of a video recording on 05/201/17 showed Staff W observed Patient #6 on the floor of her ED room, but did not enter her room to assess if she needed medical attention. Staff W left Patient #6's room and walked down the hall to Patient #7's room and motioned for the patient to follow him down the hall. Staff W pointed towards Patient #6's ED room while he looked at Patient #7 (as if to show Patient #7 what was in Patient #6's room). Staff W then placed his hand on Patient #7's shoulder and turned him around toward his ED room (#10) in a forceful manner that caused Patient #7 to move rapidly forward and stumble before he regained his balance.

Staff W saw Patient #6 lying on the floor but failed to assess her. Staff W then inappropriately showed Patient #7 the patient lying on the floor, then physically and psychology abused Patient #7.

3. During an interview on 06/07/17 at 12:55 PM, Staff D, Chief Nursing Officer (CNO), stated that:
- On 05/22/17 she reviewed the video recording of an event with Staff W, RN and Patient #7, and she knew she had a "term" (termination).
- She stated that there were three forms by Staff W of abuse to Patient #7; he pushed the patient, he humiliated the patient, and he neglected a patient.
- She was responsible for the nursing staff, and she did not feel "alarmed" by the event.
- It was her responsibility as the director to help staff make the decision to remove the alleged perpetrator (AP) from patient care.
- As the CNO, she failed and the house supervisor and the charge nurse failed to follow policy removing Staff W, RN, from all patient care.
- She was aware of the staff's fear of retaliation for reporting abuse. The staff feared that they would be labeled as a "tattletale" by their coworkers.
- No disciplinary actions were taken of the staff for failing to report or intervene in the abuse.
- She had not addressed the lack of assessment by Staff W of Patient #6's fall as neglect.

During an interview on 06/07/17 at 2:00 PM, Staff F, President, stated that:
- Policies that pertained to patient safety were his responsibility.
- On 05/22/17, he was made aware of the event that occurred on 05/20/17 with Staff W, RN, and the House Supervisor and/or Chief Nursing Officer should have removed Staff W from all patient care.
- He was unaware that the staff feared reporting events of abuse because they felt that they would be retaliated against.

During an interview on 06/07/17 at 12:20 PM, Staff G, RN, Quality, Compliance and Risk Manager, stated that the facility leadership staff had not yet recognized the failure of the delay in assessment to Patient #6 by Staff W, RN after the patient fell or the need to educate facility staff regarding patient falls and the need for immediate assessment.

This failure of the governing body to ensure the facility followed the policy and procedures on abuse and neglect that fostered a healthy, safe, and supportive environment for recognizing and reporting abuse had the potential to place all patients at risk for abuse and neglect.


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Based on interview, record review, policy review and video recording review the facility failed to:
- Protect one patient (#7) of one patient in the Emergency Department (ED) from physical and psychological abuse by Staff W, Registered Nurse (RN).
- Provide an immediate physical assessment of one patient (#6) of one patient in the ED when Staff W, RN found her lying face down on the floor.
- Protect all patients from the potential for abuse and neglect when three senior nursing staff (D, L and M) failed to immediately remove Staff W, RN from all patient care areas pending investigation.
- Address abuse intervention and reporting with two staff members (P and J) who were aware of the incident but failed to intervene and report.
Please refer to C-0296.

These deficient practices resulted in the facility's non-compliance with specific requirements found under the Condition of Participation: Provision of Services. The facility census was 22.

The severity and cumulative effect of these practices had the potential to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ).

On 06/06/17, after the survey team informed the facility of the IJ, the staff created educational tools and began educating all staff and put into place interventions to protect the patients.

As of 06/08/17, at the time of the survey exit, the facility had provided an immediate action plan sufficient to remove the IJ by implementing the following:
- An Abuse and Neglect Quick Guide was developed that described the steps for intervention and investigation when abuse is suspected or reported and required management to review the video surveillance (when available for the patient care area/location). Facility management is to include review of the Quick Guide monthly during senior staff meetings.
- Administration and management staff provided and received updated education for promoting safe environment and abuse/neglect reporting policy that reflected current State definitions together with immediate staff response and interventions to observed abuse occurrences including immediate removal and suspension of involved staff from all patient care areas.
- Administration and management staff provided and received education for promoting safe environment with emphasis on prompt response to patient falls including patient assistance, assessment/re-assessment, and reporting requirements.
- Education began to all facility staff on abuse/neglect with scenarios, reporting of incidents to ensure a safe patient care environment.
- Education began to all facility staff on fall prevention with emphasis on the immediate response, and assessment/re-assessment of the patient, documentation, and reporting steps.
- Unscheduled/unannounced observed mock scenario drills for abuse and neglect and falls began to all staff starting with clinical staff within high risk and targeted areas (Emergency Medical Systems, ED, Geriatric Psychiatric unit, Medical/Surgical and Critical Care Unit) daily during all shifts (two per day) for two weeks, then daily rotating shifts until revisit occurs.
- Unscheduled/unannounced mock scenarios/drills for abuse and neglect for all non-clinical areas (administration, offices) will occur daily for two weeks then three times a week until revisit occurs.
- Abuse and Neglect Policy was updated with added policy statement that the facility will provide a safe environment for all patients; reports of abuse occurring within the facility or involving hospital employees will be immediately investigated including the immediate intervention to secure the patient's safety with the removal of the abuser (including any involved facility employees) from all patient care areas; immediate notification of the house supervisor with notification to the facility president following the initial management response to secure the patient; immediate suspension of involved employees following the event pending investigation;
- Review of all video surveillance will be reviewed promptly but no later than 24 hours following an incident; no retaliation or bullying will occur toward reporting patients and employees and final reports indicating substantiated investigation of the report of abuse will be made by the facility and reviewed by the President.
- Staff D, Chief Nursing Officer; Staff L, RN, Charge Nurse; and Staff M, RN, House Supervisor, were suspended effective 06/08/17 pending investigation due to their failure to follow P/P and immediately respond and remove the suspected employee from direct clinical duties.
- Staff J, ED Administrative Assistant and Staff P, ED RN were suspended effective 06/08/17 pending investigation due to their awareness of the incident but failed to intervene or report.
- Policy revisions for abuse/neglect investigations will include direction for facility House Supervisors and Administrative staff who initially respond following a report to notify the facility president as soon as the chain of command has been activated. House Supervisors to receive this education prior to their next shift.
- Security will not be used as patient sitters during their security shifts.

Based on interview, record review, policy review and video recording review, the facility failed to ensure:
- Nursing staff provided two (#6 & #7) out of two discharged emergency department (ED) patients with on-going evaluations and assessments to meet their care needs, health status and responses to interventions.
- Nursing assessed one (#6) of one discharged ED patient in a timely manner after finding the patient on the floor.
- Staff was removed from all patient care after alleged allegations of abuse and neglect were reported for two (#7 and #6) of two discharged ED patient's reviewed.
- All staff was educated and trained after alleged allegations of abuse and neglect were reported.
- All staff was educated and trained after a patient had fallen and was left unattended and not immediately assessed.
These failed practices had the potential to place all patients at risk for abuse and neglect. The facility census was 22.

Findings included:

1. Record review of the facility's policy titled, "Abuse, Neglect, Child, Disabled, Domestic, Elder and Patient Abuse," revised 06/2017, showed that:
- Any employee that witnessed alleged employee to patient abuse should immediately intervene and ensure the employee is removed from patient care.
- Emotional or Psychological Abuse was willful infliction of mental or emotional anguish by threat, humiliation, intimidation, or verbal or nonverbal abusive conduct (e.g. called names, treated as a child, frightened, humiliated, intimidated, threatened, isolated, blamed.)
- Active Neglect was willful failure by the caregiver to fulfill his/her obligations or duties (e.g. deliberate abandonment of health-related services).

2. Record review of Patient #7's ED History and Physical (H&P) dated 05/20/17 at 9:39 PM, showed that:
- The patient was a 31 year old male who was brought into the ED by Law Enforcement (LE) for possible suicidal ideation (thoughts of killing self,) with a plan to hang himself.
- The patient had a medical history of Alcoholism, Hypertension (high blood pressure), and Neuropathy (problem with nerves that result in pain and numbness in arms and legs).
- The patient had a potential for self-harm and elopement precautions. He was placed on line of site or was to have a sitter.

Record review of an affidavit for admission for a 96 hour hold (lawful admission of a person who exhibits behavior and/or had likelihood of serious harm to himself or others) dated 05/20/17, showed that LE #1, and LE #2 documented that Patient #7 stated that he was going to hang himself with his belt.

3. Record review of Patient #6's H&P dated 05/20/17 at 2:54 PM, showed that:
- She was a 63 year old female, who presented to the ED, by ambulance with complaints she was hot and tired and was found in her home lying in the bathroom on a mattress.
- The patient was discharged from another facility on 05/19/17 for suicidal and psychosis.
- The patient had a history of brain tumor, seizures, Porphyria (increase of porphyrines, a chemical in the body needed for the function of hemoglobin, which is a protein in red blood cells that carries oxygen to organs and tissue), Encephalitis (infection of the brain), and hip problems.
- The patient's laboratory results showed Hemoglobin level (amount of red blood cells, low level may indicated a need for blood administration) levels of 6.2 g/dL (unit of measurement, normal range 11.9-15.5 g/dL.)

Record review of Patient #6's nurses' notes dated 05/20/17 at 3:00 PM, showed that staff assessed the patient's fall risk was high and fall precautions (actions to help reduce falls) were taken.

4. Review of the facility's video recording dated 05/201/17 from 11:50 PM to 11:51 PM showed Staff W observed Patient #6 on the floor at approximately 11:50 PM but did not enter her room to assess if she needed medical attention. Staff W was seen leaving Patient #6's room and walked down the hall to Patient #7's room and motioned for the patient to follow him down the hall to Patient #6's room. Staff W showed Patient #7 that Patient #6 was lying on the floor.

Staff W, RN failed to immediately asses Patient #6 for possible injuries for approximately one minute after he was aware that she was face down on the floor. This delay in assessment occurred when Staff W asked Patient #7 to follow him down the hallway so that Patient #7 could see Patient #6 lying on the floor. Staff W's failure to immediately assess Patient #6 had the potential to delay treatment for possible injuries.

During an interview on 06/06/17 at 2:15 PM, Staff J, Administrative Assistant, stated that:
- She had worked in the ED and monitored the unit desk the night of 05/20/17.
- She saw Staff W walk towards Patient #6's room and the patient was on the floor.
- Staff W left the patient alone in the room on the floor.
- Staff W walked down to room #10 and had Patient #7 follow him down toward Patient #6's room.
- Staff W pointed to Patient #6, who was lying on the floor, and told Patient #7 that he had a patient dying in room #3 and he had wasted 30 minutes dealing with him.

Staff J, Administrative Assistant, observed that Staff W failed to assess and administer care to Patient #6 after she was found on the floor but did not alert other staff that Patient #6 was on the floor and was possibly injured.

5. Record review of the Security Incident form, dated 05/20/17 at 3:30 AM, showed documentation by Staff V, Security/Patient Safety Companion that:
- She reviewed the video monitoring dated 05/20/17.
- Staff W, ED RN told the patient (#7) to "come over here" and follow him.
- Staff W and Patient #7 walked down the hallway toward Patient #6's ED room #3.
- Staff V watched while she stood at the door of room #10.
- The family watched from room #10's doorway.
- Staff W, took the patient (#7) near Patient #6's ED room #3, pointed and said something.
- Patient #7 returned to room #10 and told her that Staff W showed him a dead body.

During a telephone interview on 06/07/17 at 9:50 AM, Staff W, RN, stated that:
- He had worked in the ED as a staff nurse on 05/20/17 and remembered the event that took place with Patient #6 and Patient #7.
- Patient #7 was suicidal, on a 96 hour hold, non-compliant, and was "monopolizing" his time.
- Patient #6 had a Gastrointestinal bleed (bleeding in the system between the mouth and the rectum) and that she needed a blood transfusion.
- He had argued with Patient #7 and the family about the patient.
- He left Patient #7's room and walked toward room #3 and he saw Patient #6, lying on her side, face down, on the floor.
- He left Patient #6 lying on the floor because he was "frustrated".
- He walked down the hallway, got Patient #7 and walked toward room #3, where Patient #6 was lying on the floor.
- He pointed to Patient #6 and told Patient #7, that he had taken all of his time, and he should have been taking care of Patient #6 instead.
- Patient #7 asked him if she was dead.
- He finished the shift on 05/20/17, and worked the next night shift on 05/21/17.

Staff W, RN failed to immediately assess Patient #6, and identified Patient #7 as "monopolizing his time".

During a telephone interview on 06/06/17 at 9:55 AM, Staff P, ED RN, stated that he worked the ED on the night of 05/20/17 and he saw Staff W point and told Patient #7, "I'm tired of your crap, I'm trying to take care of sick and dying patients, get back to your room". He stated that Staff W in a "forceful" manner turned Patient #7 around and walked Patient #7 toward room #10.

Staff P, RN, observed and heard Staff W verbally and physically abuse Patient #7 but did not intervene or alert other staff.

During an interview on 06/06/17 at 11:30 AM, Staff L, ED Charge Nurse, stated that:
- She had abuse and neglect training on reporting, but did not remember anything about removing Alleged Perpetrator from all patient care.
- Staff W, RN had been "aggravated" for months with psychiatric patients taking care away from critical ill patients.
- Staff W told her that Patient #6 fell out of bed because he was taking care of the psychiatric patient (Patient #7).
- She notified Staff M, House Supervisor, of the event.
- Staff W continued to take care of other patients until 7:00 AM the next day.

During an interview on 06/06/17 at 11:00 AM, Staff M, House Supervisor, stated that:
- He was House Supervisor on the night of 05/20/17 and Staff L, ED Charge Nurse, called him about the event between Staff W and Patient #7.
- The mother of Patient #7 told him that Staff W showed the patient a "dead body".
- He spoke to Staff W who was "extremely frustrated," and "extremely upset," and told him that he was spending too much time with Patient #7.
- The call list (list of administration personal that are on call) was down, so he called Staff D, Chief Nursing Officer (CNO), and told her that Staff W had been reassigned to other patients.
- Staff D, CNO never discussed removing Staff W from all patient care.
- He was aware that Staff W remained taking care of patients the rest of the night and the next night shift on 05/21/17.

Staff M, House Supervisor, had knowledge that Staff W was "extremely frustrated," and "extremely upset" about the ongoing assessments and taking care of needs of patients. Staff M, House Supervisor did not remove Staff W from patient care and allowed him to complete his shift.

During an interview on 06/07/17 at 12:55 PM, Staff D, CNO, stated that:
- She was not the administrator on call on 05/20/17, but staff frequently called her.
- Staff M, House Supervisor, called her around 12:30 AM on 05/20/17 and told her that Staff W "inappropriately showed a patient a dead person."
- She did not feel "alarmed" by the event.
- It was her responsibility as the director to help staff make the decision to remove staff that was involved in alleged abuse from patient care.
- As the CNO, she failed, the house supervisor failed, and the charge nurse failed to follow policy as they did not remove Staff W, RN, from all patient care.
- She reviewed the video recording on 05/22/17 at 8:30 AM and she knew she had a "term" (termination).
- There were three forms of abuse/neglect by Staff W; he pushed the Patient #7, he humiliated the patient (#7), and he neglected the Patient (#6).
- She had not addressed Patient #6's fall as abuse or neglect.
- She was not aware of any education or training for front line staff on abuse/neglect following this incident.

Staff L, RN, ED Charge Nurse, Staff M, RN, House Supervisor and Staff D, CNO, were all aware of the alleged abuse and neglect by Staff W and allowed him to care for patients and work a full shift the following day. Staff W, RN was not suspended until 05/22/17; two days after the event occurred.

During an interview on 06/05/17 at 3:25 PM, Staff Q, ED Clinical Leader, stated that:
- She had not completed any new abuse/neglect training since 05/20/17.
- There was online training on abuse/neglect due by 06/09/17.
- The annual abuse/neglect training instructed that staff report immediately.
- She could not remember if the training had specifically said to remove the AP from patient care.

During an interview on 06/05/17 at 3:31 PM, Staff A, Registered Nurse (RN), stated that she had not received any recent training or education from the facility related to abuse and neglect. Staff A stated that she had not received any abuse and neglect training or education from the facility during the month of May 2017.

During an interview on 06/05/17 at 3:45 PM, Staff B, Certified Nursing Assistant (CNA) stated that the facility had not done any training or education related to abuse and neglect since the first of the year and none in May 2017.

During an interview on 06/05/17 at 4:10 PM, Staff C, RN, Mother Baby Manager, stated the facility had not done any current abuse and neglect training or education with front-line staff. Staff C stated that the facility did have an update about abuse and neglect for supervisors and managers approximately two weeks ago that dealt with the process to follow for suspected abuse and neglect from staff, patients or visitors.

During an interview on 06/05/17 at 4:35 PM, Staff T, ED RN, stated that she had annual training for abuse and neglect, and her only role was to report abuse. It was not her responsibility to intervene immediately with a staff member's removal from the patient that was being abused.

During an interview on 06/06/17 at 10:27 AM, Staff X, RN, Clinical Nurse Manager-Psych Unit, stated that front-line staff had not received any training or education for abuse and neglect since May 21, 2017. Staff X stated that supervisors and managers recently received training about abuse and neglect that included a test. Staff X stated that the facility provided supervisors and managers with a quick guide for abuse and neglect around the end of May. Staff X stated that as far as she knew the training was just an update without a policy change and the update was not related to an event or incident.

During an interview on 06/06/17 at 10:45 AM, Staff Y, RN, stated that she had not received any abuse and neglect update, education or training since May 21, 2017.

During an interview on 06/06/17 at 10:50 AM, Staff H, RN, Assistant Nursing Manager, Medical-Surgical and Critical Care Unit, stated that the front-line staff had not received any additional training or education recently for abuse and neglect.

During an interview on 06/07/17 at 12:20 PM, Staff G, RN, Quality, Compliance and Risk Manager, stated that the facility leadership staff had not yet recognized the failure of the delay in assessment to Patient #6 by Staff W, RN after she had fallen or the need to educate facility staff regarding patient falls and the need for immediate assessment.





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