HospitalInspections.org

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Based on interview, video review and policy review, the facility failed to protect patients from potential abuse while investigating an abuse report for 1 patient (#1) out of 7 patients in the Psychiatric Emergency Department (ED). This failed practice of not identifying the potential abuse and not protecting patients from further abuse during the investigation by not removing the caregiver from the schedule, had the potential to place patients at further risk of abuse. Findings:

During an interview on 8/4/22 at 9:20 AM, Security Officer's (SO) #1 and # 2 stated when an unusual event was recognized, security guards would have filed an incident report and discussed the event with their supervisors. SO's # 1 and # 2 further stated all officers wore body cameras and the cameras were activated immediately upon any dispatch requests.

During a joint video review and interview on 8/4/22 at 9:40 AM, SO # 2 reviewed the video from 5/22/22 entitled "Psych[iatric] 5-22-22 short." Video observation from the Psychiatric ED revealed Patient # 1 appeared agitated and was pacing. Licensed Nurse (LN) # 1 stated to Patient # 1 to take the medications, or he/she would be placed in restraints. Further review revealed the patient was not offered any food or water. When the Patient refused the medications, LN # 1 ordered the restraints and the SO's on duty assisted with placing the patient in the restraints, while the LN administered the medication intramuscularly in the patient's hip area. During the restraint episode, Patient # 1 threatened to bite the staff. LN # 1 responded "You're gonna get your teeth knocked the fuck out if you bite anybody, so shut your fucking mouth, I'm sick of you already, I just got here."

While observing the video, SO # 2 stated the officers involved were "taken aback" by the LN talking to the patient that way. SO # 2 further stated the officers filed an incident report that night and the report was placed in the datix system (facility's reporting mechanism) by the supervisor the following day (5/23/22). The SO further stated the datix report would have been reviewed by risk management.

During an interview on 8/4/22 at 9:52 AM, when asked the process to report claims of potential abuse toward a patient, Nurse Manager (NM) # 1 stated it was his/her duty to report such a claim. NM # 1 stated he/she would have spoken to the patient to gather information, work with the patient satisfaction group, then speak with the employee involved. The NM further stated he/she would have collaborated with Human Resources (HR) and would have removed the caregiver from the schedule during the investigative process.

During an interview on 8/4/22 at 10:20 AM, the Psychiatric ED Manager stated Patient # 1 was intoxicated, delusional and angry. When asked about de-escalation for a patient in crisis, the Psychiatric ED Manager stated staff should never use food or drink as negotiation tool, and staff were taught to remove themselves from situations when feeling triggered by a patient. The Psychiatric ED Manager further stated she informed the managers to not staff LN # 1 in the Psychiatric ED, but she believed LN # 1 had worked there one additional time.

During an interview on 8/4/22 at 11:36 AM, the Quality Director (QD) stated a gap was identified and when the Datix report was reviewed, the abuse was not recognized as abuse, instead it was recognized as bad behavior by a leader new to his/her position. The QD stated the concern was the failure to recognize the risk to the patients. The QD further stated LN # 1 had worked with patients until the facility recognized the event as potential abuse, at which time the employee was placed on administrative leave.

During an interview on 8/4/22 at 1:02 PM, NM # 2 stated he/she became aware of the incident on 5/25/22 and reviewed the facility's video on 6/6/22. The NM stated LN # 1 was on vacation from 5/24-6/16/22, so the facility had some time to investigate since the employee was not on the schedule to work. NM # 2 expressed he/she was focused on the appropriateness of placing the patient in restraints during the initial review of the video footage. NM # 2 further stated he/she interviewed LN # 1 and decided to go back and review the video footage a second time. The NM stated the comment LN # 1 made to the patient became more apparent during the follow up video review.

When asked about the disposition of LN #1, the NM stated LN # 1 was placed on administrative leave on 8/1/22 but had worked 21 shifts in multiple areas of the facility prior to recognizing the incident as potential abuse. NM # 2 further stated he/she was unsure if LN # 1 was safe to work with the patients.

Review on 8/4/22 at 2:00 PM of the facility's policy, "Protection of Vulnerable Adults from Abuse, Neglect, and Exploitation," dated 3/2020, revealed "Alleged or suspected abuse, neglect, or exploitation of a vulnerable adult by a staff member of PAMC [Providence Alaska Medical Center] is reported to the appropriate authorities. Staff who are suspected of abuse, neglect, or exploitation are placed on suspension pending investigation."

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