HospitalInspections.org

Based on review of policy and procedure, Code of Conduct, personnel file, and interview, it was determined that the chief executive officer failed to be responsible for the management of the hospital as evidenced by:

1. failure to ensure that a vulnerable child patient was maintained in a safe environment, when the child was "slammed" into a door by a Behavioral Health Technician (BHT). There is a grave potential risk to the physical and emotional health of a highly vulnerable child being assaulted in a psychiatric hospital environment.

2. failure to ensure that the assault of a vulnerable child patient by a BHT was reported to law enforcement as required by policy. The potential risk is that the failure to report the assault leaves patients in other psychiatric or behavioral health facilities at risk of assault by the BHT should he/she seek subsequent employment in a psychiatric setting.

Findings include:

1. Cross reference Tag (A0145) regarding the assaul of a vulnerable child patient by a Behavioral Health Technician (BHT), when eyewitnesses described the child being "slammed" into a closed door.

2. Cross reference Tag (A0145) regarding the failure of licensed persons, employed by the hospital, to report the child assault to legal authorities.

Based on review of hospital policies and procedures, medical records, documents, Code of Conduct, personnel file, and interviews, it was determined that the hospital failed to protect and promote each patient's rights as evidenced by:

(A144) failure to ensure that patients received care in a safe setting, posing a risk to the health and safety of patients; and

(A145) failure to ensure that a child patient was maintained in a safe environment.

(A0117) failure to notify a child's parent of assault on a child.

The cumulative effect of these systemic problems, and the egregious assault of a vulnerable child patient, resulted in the hospital's failure to meet the requirements of the Condition of Participation for Patient Rights.

Based on review of the medical record, policy and procedure, and interview, it was determined that the Hospital failed to assure the patient's right to receive assistance of a family member, when the patient's parent was not informed of the the child's assault. The potential risk is that the patient continued to be hospitalized in an unsafe setting, without his/her representative (parent) being aware of the risks of continued hospitalization at the hospital.

Findings include:

The Sonora Behavioral Health Hospital policy titled: "Patient Rights and Responsibilities" revealed: "...PURPOSE: To assure all patients are aware of their options and obligations...4. Patient Surrogates- Patient rights, care, comfort and service are a priority at (hospital). While patients are recognized as having the right to participate in their care and treatment to the fullest extent possible, there are circumstances under which the patient may be unable to do so. In these situations, the patient's rights are to be exercised by the patient's designated representative or other legally designated person. In the event that a patient can't make or communicate health care decisions and has no advance care directives, decision makers must be chosen in this order...5. Parent of patient...EACH PATIENT HAS THE RIGHT TO: 8. To receive assistance from a family member, designated representative, or other individual in understanding, protecting, or excising the patient's rights...."

Cross reference Tag (A0145) regarding a child under the age of ( specific age identified) who was assaulted by a Behavioral Health Technician by being "slammed into a closed door.

Review of Patient #1's medical record revealed no documentation that the patient's parent had been notified of the assault.

Staff #16, the Assistant Director of Nursing, stated during interview conducted on 05-05-16 at 8:45 A.M., that the child's parent had not been notified of the assault.

Based on review of medical record, documents, policy and procedure, Code of Conduct, personnel file, and interview, it was determined that a safe setting was not provided to a vulnerable child patient (Patient # 1), who was assaulted by a Behavioral Health Technician (BHT # 1), according to eyewitnesses. This posed a high potential risk of grave physical and emotional injury to a vulnerable child patient.

Findings include:

Cross reference Tag (A0145), in which a child, made decidedly vulnerable by diagnoses, weight and stature, and psychiatric hospitalization, was assaulted by a BHT with no documention of provocation.

Based on review of medical record, document review, policy and procedure, Code of Conduct, personnel file, and interview, it was determined that a patient was not maintained in a safe setting/environment, when a child patient was assaulted by a Behavioral Health Technician (BHT # 1), who according to eyewitnesses, reported that the child was "slammed" into a locked door (Patient # 1). This posed a high potential risk of grave physical and emotional injury to a vulnerable child.

Findings include:

The "Patient Rights and Responsibilities" "Clinical Rights" revealed: "...EACH PATIENT HAS THE RIGHT TO: 1. Be treated with dignity, respect, and consideration...19. To be free from: a. Abuse...."

The (Corporation) "Code of Conduct" revealed: "This Code of Conduct is an integral component of the (Corporation) Program. Our intent in developing the Code is not only to document (Corporation's) legal and ethical compliance requirements, but also to encourage each of us to regularly think about our actions and the consequences of our behavior in the workplace...Zero Tolerance Policy (Corporation) has and strictly enforces a Zero Tolerance policy prohibiting resident or patient physical or emotional abuse including but not limited (to) verbal or physical abuse, use of undue force...."

The (Corporation) "Patient Abuse and Neglect" policy revealed: "It is the policy of (Corporation) that no patient is to be mistreated or abused physically, verbally, psychologically...while in our care...Patient abuse is strictly prohibited...."

The "Abuse, Exploitation or Neglect Reporting-Child or Vulnerable Adult" policy revealed: "Policy: Appropriate reporting occurs when suspicion arises that a patient may have been or is at risk for abuse...Physical Abuse is a form of abuse which results in physical injury or injuries to a child under the age of eighteen years...Physical indicators...Missing or loose teeth...LEGAL REQUIREMENT TO REPORT CHILD ABUSE Legal Requirements to Report: Arizona Statute 13-3620 states: 'Any physician, hospital intern or resident...nurse...social worker...or any other person having the responsibility for the care or treatment of children whose observation or examination of any minor is or has been the victim of injury...which appears to have been inflicted upon such minor by other than accidental means...."

Patient # 1, a child younger than age (specific number identified), was admitted to the Child and Adolescent Unit after an episode in which the child was physically aggressive with others. The "Psychiatric Evaluation" revealed, among several psychiatric diagnoses, [specific name] Disorder. The evaluation revealed that the child had a weight of (specific number identified) pounds, and a height of (specific number identified) inches (specific number identified feet, (specific number identified inches).

The "(Hospital) Behavioral Health Observation Rounds" documentation dated 12-25-15, revealed the following for Patient # 1:

11:30 A.M. Location: Art (Room)
Behavior: Cooperative

11:45 A.M. Location: Art
Behavior: Cooperative

12:00 P.M. Location: Art
Behavior: Cooperative

12:15 P.M. Location: Cafeteria
Behavior: Cooperative

12:30 P.M. Location: Cafeteria
Behavior: Cooperative

12:45 P.M. Location: Patient Room
Behavior: Cooperative

1:00 P.M. Location: Dayroom
Behavior: Cooperative

An internal document of a witness account revealed that the date and time of the incident was 12-25-15 at 12:30 P.M. A second witness account revealed an incident time of 1:00 P.M. The second account revealed: "...then slam the youth into the unit door...."

A hospital document revealed: "Witnesses described...(BHT) having ahold of the patient's arm while walking the patient back to the (Child and Adolescent) unit from the cafeteria...while being overheard stating to the patient 'You don't know who you are dealing with' as they walked through the breezeway and the patient stating 'Ow.' A witness described (BHT's) tone as 'angry and hostile.'...It was further substantiated by other witnesses that (BHT) was observed to have 'slammed' or 'pushed' the...patient into (Child and Adolescent) unit locked door...(BHT) violated the Zero Tolerance policy by... and acting in an aggressive manner leading to the abuse of a patient...."

On 12-25-15, Staff #15, the Assistant Director of Nursing at the time, documented: "Writer spoke c (Latin for abbreviation for 'with') pt. (patient) re (regarding): coming back from cafeteria. Pt did not say why she/he was brought back. Did not want to talk about it. Very fidgety-moving around constantly-Skin assessment of upper arms-L (Left) upper arm slight redness on inner aspect...."

A nursing note several days following the assault documented that the patient lost a tooth (specific tooth unknown) "due to normal aging."

Staff #17, the Director of Health Information Management (HIM) stated, during interview conducted on 05-04-16 at 4:10 P.M., that she was unable to find documentation that a referral had been made regarding the assault to the Arizona Department of Child Safety.

Staff #16, the Assistant Director of Nursing, stated, during interview conducted on 05-05-16 at 8:45 A.M., that there was no record that anyone at the hospital had reported the assault to The Department of Child Safety or to law enforcement.