HospitalInspections.org

Based on interview and record review, the facility failed to protect Patient #1 from physical and verbal abuse by Tech #1. Abuse is defined by the experience of the Patient. This failure by the hospital resulted in physical and emotional abuse to Patient #1. The facility failed to provide a safe setting for 1 (P #1) of 10 (# 1-10) sampled patients reviewed for patient rights. If the facility is not keeping patients safe then they are at risk of being abused by staff. The findings are:

A. On 03/19/18 at 3:30 pm during interview, P #1 reported the following:

He was asked if he had a bad experience at Haven during his last admission.
He stated, "I did...On the 3rd or 4th evening I needed to go pee. I had an accident and urinated on myself and the floor. A tech named [Tech #1] was really rough with me. He pulled me off the bed. And when I called him a "dumb Mexican" he made me bend over and jammed a jammed a towel between my butt (cheeks). According to P #1, Tech #1 stated, "I'll show you who is a dumb Mexican" and shoved the towel into his groin/butt. P #1 also stated, "there were other young women, [staff ] witnessing this."
P #1 stated, "I apologized later but [Tech #1] was still aggressive."
He also stated, "I would be afraid to go back there."
"You mean retaliation?" the interviewer asked."Yes," he replied.
P #1 stated he did not report any events or concerns to the staff at the hospital at any time.

B. Record review of the medical record for Patient #1 indicated he has been diagnosed with Parkinson's disease, a neurological, degenerative disease.

C. On 03/18/18 at 09:30 am via telephone interview, the Adult Protective Services Investigator reported the following:
1. P #1 believed his stay at Haven was between 02/15/18 and 02/25/18.
2. He did not remember a name or a description of the tech but described the "assault" similarly as above.
3. He did not remember the date of the event.
4. He did not report anything to the nurses or any other staff. P #1 was never examined by staff for injuries at any time.
5. P #1 was, according to the Adult Protective Service investigator who first took his complaint, reluctant to discuss this event with the investigator.

D. On 03/20/18 at 12:30 pm during interview, Tech #1 stated the following:
1. I don't remember this man, when showed a picture of P #1.
2. P #1 was present in the facility between 02/08/18 and 02/18/18. When asked, "Do you remember any event with this patient?" He stated, "I do not remember any bad events."
3. When asked, "Do you remember any issues when you were with him on 02/11/18 all shift in a one-to-one?" Again he stated, "No." He was asked, "So you were with him all shift, 12 hours, and you don't remember the night?" He said, "No."

E. On 03/22/18 at 12:15 pm during phone interviews, Tech #2 and Tech #3 both stated they could not remember any events between P #1 and Tech #1 on the night of 02/11/18 or any other night during P #1's stay at the hospital.

F. Record review of P #1's medical record for the stay between 02/08/18 and 02/18/18 the following was noted:
1. Daily progress notes by the physician indicated no change in demeanor or behavior on or after 02/11/18.
2. Daily nursing notes indicated no change in demeanor or behavior on or after 02/11/18.
3. Daily tech notes indicated no change in demeanor or behavior on or after 02/11/18.

G. Record review the hospital's incident log for the period between 02/08/18 and 02/18/18 revealed no incident reported regarding P #1. The approximate date of the event was 02/11/18 based on the statements of the Patient and the presents of Tech #1 in a one-to-one with P #1.

H. Record review of the hospital's policy titled "Abuse Reporting" last revised 08/17 indicated the following: "Patients have the right to be free from mental, physical, sexual and verbal abuse, neglect and exploitation. It is the policy of this hospital to protect patients from real or perceived abuse, neglect and exploitation from anyone including staff members, students, volunteers, other patients, visitors or family members..."