HospitalInspections.org

Based on a review of facility documents, medical records (MR), and interviews with staff (EMP), it was determined that East End Behavioral Health Hospital failed to protect a patient's rights by failing to follow their complaint and grievance process (A-118); failed to follow processes for patient allegations of abuse, and failed to thoroughly investigate these allegations (A-145); and failed to follow their policies with regard to physical restraints (A-154).



Cross Reference:
§482.13(a)(2) Establish a process for prompt resolution of patient grievances
§482.13(c)(3) Free from abuse/harassment
§482.13(c) Restraint or seclusion

Based on a review of facility documentation and medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure they followed their complaint and grievance process for nine of nine complaints reviewed (MR1, MR11, MR12, MR13, MR14, MR15, MR16, MR17, and MR18).

Findings include:

On July 19, 2023, a review of facility policy, BHH-Patient Complaint & Grievance Process, dated February 1, 2022, revealed, "Definitions. Complaint-dissatisfaction with any aspect of the hospitalization including, but not limited to, physical care, medical care or treatments, discharge planning, communication, etc. The matter is immediately addressed and resolution is quick and complete. No written response is given. Patient Grievance-a written or verbal complaint (when the verbal complaint about patient care is not resolved at the time of the complaint, by staff present), by a patient, or the patient's representative...Procedure A. Complaints...All complaints and resolutions will be documented on a Complaint form and kept in Administration."

On July 19 and 20, 2023, a review of the facility complaint/grievance logs for May 2022-July 2022, and January 2023-March 2023, was completed.

The May 2022, log revealed that on May 18, 2022, MR1 complained that staff were violating her rights, was forcefully grabbed by staff and escorted to her room. The log documented this as a complaint. The log revealed the interim response was "attempted to have discussion, watched camera footage." The final response was documented as "not able to come to an agreement. Spoke w/husband." Under "status" the log revealed, "Patient d/c [discharged] continues to have multiple complaints."

During an interview on July 19, 2023, at 11:30 AM, EMP2 confirmed, "It should have been considered a grievance because there were multiple complaints." Upon further interview, EMP2 confirmed the facility failed to follow their own policy.

A review of the facility's complaint/grivance log on July 20, 2023, revealed the following:


On May 3, 2022, MR11 was upset about not being discharged and being kept at facility for no reason. A copy of the complaint form was requested, none was provided.


On May 3, 2022, MR12 was upset because staff took her comb, says therapist gets in her face and uses his hands and moves around making her nervous. A copy of the complaint form was requested, none was provided.


On May 6, 2022, MR13 complaint about staff and reported another patient is too loud. A copy of the complaint form was requested, none was provided.


On July 7, 2022, MR14 complained about something biting her and that staff entered the room without knocking. A copy of the complaint form was requested, none was provided.


On July 25, 2022, MR18 complained that she was given medication without her consent. A copy of the complaint form was requested, none was provided.


On January 23, 2023, MR15 complained that staff were making fun of her and was upset about staff making accusations. A copy of the complaint form was requested, none was provided.


On January 23, 2023, MR16 complained that another patient became upset about the television and nothing was being done. A copy of the complaint form was requested, none was provided.


On March 22, 2023, MR17 complained of unfair treatment during treatment team. A copy of the complaint form was requested, none was provided.


During an interview on July 20, 2023, at 2:45 PM, EMP2 confirmed the facility failed to follow their policy for complaints and grievances and could provide no further information for the above complaints.

Based on a review of facility documentation and medical records (MR), and staff interview (EMP), it was determined the facility failed to follow processes for patient allegations of abuse and failed to thoroughly investigate 14 of 14 allegations reviewed (MR1, MR2, MR19, MR20, MR21, MR22, MR23, MR24, MR25, MR26, MR27, MR28, MR29, MR30).


Findings include:


On July 19, 2023, a review of the facility policy, BHH-Patient Complaint & Grievance Process, dated February 1, 2022, revealed, "Definitions. Complaint-dissatisfaction with any aspect of the hospitalization including, but not limited to, physical care, medical care or treatments, discharge planning, communication, etc. The matter is immediately addressed and resolution is quick and complete. No written response is given. Patient Grievance-a written or verbal complaint (when the verbal complaint about patient care is not resolved at the time of the complaint, by staff present), by a patient, or the patient's representative...Procedure A. Complaints...All complaints and resolutions will be documented on a Complaint form and kept in Administration."

On July 19, 2023, a review of the facility policy BHH-Abuse, Neglect, Assault Alleged or Suspected, dated April 2023, revealed, "Policy, Employees will report any suspected abuse or neglect of a patient. All accusations of physical, emotional, or psychological abuse of any patient necessitate immediate action...Procedure...B. Staff Member Witnessing Event or Receiving Allegation of any type of abuse: 1. Upon receiving an allegation, the staff member is to immediately assure patient safety...d. Notify Department Manager or designee, immediately...3. The Department Manager or designee will: a. Contact the Attending Physician to thoroughly assess the patient and document all findings such as bruises, reddened areas, abrasions, etc. in the patient's medical record...e. Complete an Incident Report and complaint form."

On July 19 and 20, 2023, a review of the facility complaint/grievance logs for May 2022-July 2022, and January 2023-March 2023, was completed.

The May 2022, log revealed that on May 18, 2022, MR1 complained that staff were violating her rights, was forcefully grabbed by staff and escorted to her room. The log documented this as a complaint. The log revealed the interim response was, "attempted to have discussion, watched camera footage." The final response was documented as "not able to come to an agreement. Spoke w/husband." Under "status" the log revealed, Patient d/c [discharged] continues to have multiple complaints."

The facility complaint file for MR1, dated May 18, 2022, included an incident report with an incorrect date of May 13, 2022, (patient wasn't admitted until May 15, 2022) and only included, "Pt was angry with staff when peer was told to put gown on. Pt. continued to yell in staff face and was defiant when rules were trying to be enforced. Pt. was escorted to room by physical force." The rest of the 4 page document was left blank.

The June 2022, log revealed that on June 1, 2022, MR1 complained again to the facility after discharge. The log revealed, "topic, multiple complaints, requesting video, bruising on upper arm."

On July 19, 2023, a request was made to see the video of the above incident. Though the video failed to capture the whole incident, it did capture EMP4 grabbing MR1 by the upper left arm and attempting to escort the patient to a different location. After EMP4 had a hold of MR1's upper left arm, the video revealed another staff assisting to escort the patient from the right side.

A review of MR1 was completed on July 19, 2023. MR1 included a number of photographs dated May 15, 2022, the date of admission. Among these were pictures of MR1's right and left upper arms showing fading bruises. Included in the record were two photos dated May 18, 2022, one of the left upper arm and one of the right upper arm. The reason for these photos could not be identified by medical record review. The photos dated May 18, 2022, (one day after incident where MR1 was physically escorted) revealed obvious new bruising to both the left and right upper arms. A nursing or physician assessment of the bruises was not found in the medical record.


During an interview on July 19, 2023, at noon, EMP1 confirmed the incident report for MR1 was not complete and there was no evidence of an investigation completed stating, "I dropped the ball." Further interview with EMP1 on July 20, 2023, at 11:45 AM confirmed that EMP1 failed to assess or notify the physician when made aware of MR1's new bruising to the upper arms. EMP1 also confirmed she failed to follow the facility abuse policy.


On July 19, 2023, an incident file of patient abuse (MR2) was reviewed. A verbal confrontation between an employee and patient occurred on April 28, 2023. Later, on April 28, 2023, a second confrontation occurred between the same employee and patient. In the second occurrence, the employee, "physically ran toward MR2...but never made contact." Management was not made aware of the allegation until May 24, 2023, 27 days after the incident. Three statements were taken regarding the above incidents. There was no documented investigatory findings available for review.

On July 20, 2023, the following grievances were identified on the complaint log:

On May 3, 2022, MR19 made an allegation of staff putting his knee in her throat when being placed in restraints. "Status" was "No findings. Closed. Letter sent to patient." The investigation was requested, none was provided.

On June 11, 2022, MR20 made allegations of inappropriate comments made by physician. The investigation was requested, none was provided.

On June 14, 2022, MR20 made allegations of inappropriate comments made by nurse. The investigation was requested, none was provided.

On June 16, 2022, MR21 called 911 to report she was being abused. The investigation was requested, none was provided.

On June 19, 2022, MR22 alleged that staff made a threatening comment. The investigation was requested, none was provided.

On July 1, 2022, MR23 alleged staff made inappropriate comment. The investigation was requested, none was provided.

On July 4, 2022, MR24 alleged staff was rude to other patients and witnessed staff yelling at other patients. The investigation was requested, none was provided.

Only July 6, 2022, MR26's daughter complained about conversation with psychiatrist and social worker. The investigation was requested, none was provided.

On July 28, 2022, MR27 alleged a rude comment from staff. The investigation was requested, none was provided.

On January 7, 2023, MR28 alleged inappropriate behavior by staff. The investigation was requested, none was provided.

On February 9, 2023, MR29 alleged improper treatment. The investigation was requested, none was provided.

On March 31, 2023, MR30 complained to his mother that he had a toothache not being addressed and concerns about diabetes, and rude staff. The investigation was requested, none was provided.

During an interview on July 20, 2023, at 2:45 PM, EMP2 confirmed the facility failed to follow their policy for investigating complaints and grievances and could provide no further information/incident reports for the above grievances.

Based on review of facility documentation, medical records (MR), and staff interview (EMP), it was determined the facility failed follow their policy with regard to physical restraints for three of six restraint medical records reviewed (MR1, MR2 and MR4).


Findings include:


On July 20, 2023, a review of the facility's policy, "Restraints Seclusion In Behavioral Health Hospital," Origin Date: April 2023, revealed, "Purpose. To establish guidelines for the utilization of devices to maximize patient safety and provide guidelines for the safe use of restraints and seclusion. Policy...The patient has the right to be free from restraints of any form that are not medically necessary.... Restraint is to be implemented in the least restrictive manner and ended at the earliest possible time...Reasons For Use...3. Record of Care, An RN assesses a patient who are [sic] restrained at least every 2 hours and attends to their personal needs to prevent or reduce potential physical and emotional complications of restraint use and to determine the continuing need for restrain. The record of care includes: type of restraint, date and time of restraint order, assessment and care provided, reassessment of the need for restraints...2. Face to Face..."

Review of MR1, on July 20, 2023, revealed that the patient had a physician's telephone order for a restraint titled, "physical hold" dated May 17, 2022.

On July 21, 2023, a review of the facility Comprehensive Crisis Management (CCM) training workbook was reviewed. This packet failed to include a type of restraint titled, "physical hold."

On July 21, 2023, at 10:30 A.M., an interview was conducted with EMP4. EMP4 was given the facility CCM workbook and asked to show the training for the physicial hold. EMP4 stated, "Physical hold is not in here."


A review of MR2 was completed on July 20, 2023. On December 28, 2021, MR2 arrived at the facility in restraints. MR2 included a restraint order sheet dated December 28, 2021, that revealed, "continue restraints." The order lacked the type of restraint, the time frame for restraint, alternatives attempted prior to the restraint, and the reason for the restraint. This order also lacked a physician signature. Further review of MR2 revealed the lack of nursing assessment, a face to face assessment, and the length of time that the patient was in this restraint.


Review of MR2 also revealed a physican restraint order dated May 1, 2022. The order lacked the type of restraint, the time frame for restraint, alternatives attempted prior to the restraint, and the reason for the restraint. Further review of MR2 revealed the lack of nursing assessment, a face to face assessment, and the length of time that the patient was in this restraint.


Review of MR2 also revealed a physican restraint order dated May 17, 2022. The order lacked the type of restraint, the time frame for restraint, alternatives attempted prior to the restraint, and the reason for the restraint. Further review of MR2 revealed the lack of nursing assessment, a face to face assessment, and the length of time that the patient was in this restraint.

A review of MR4 was completed on July 20, 2023. MR4 revealed a physician's order restraint form dated April 27, 2023, but lacked an order for the type of restraint, the time frame for restraint, alternatives attempted prior to the restraint, the specific reason for the restraint, a physician's order, or a telephone order. Further review of MR4 revealed the lack of a nursing assessment, a face to face assessment, the length of time that the patient was in this restraint, and the time the restraints were removed.

On July 20, 2023, at 11:48 A.M., EMP2 confirmed the above.