HospitalInspections.org

Based on review of facility policy, medical record review, review of facility documentation, and interview, the facility failed to ensure 2 patients (#3, #4) were free from abuse of 3 patients reviewed for abuse, of 9 patients sampled.

The findings included:

Review of facility policy, Alleged Assault or Abuse of Patients Receiving Services, last revised 8/2016, revealed "...all patients have the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. Mistreatment, neglect, and abuse of patients are prohibited...definitions: abuse: willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish..."

Medical record review revealed the Patient #3 was admitted to Facility B on 10/17/17 with a diagnosis of Schizoaffective Bipolar Disorder (affects a person's ability to think, feel, and behave clearly) with Psychotic features.

Review of facility documentation dated 10/21/17 at 10:30 PM revealed "...61 year old...soiled herself in the bed and was escorted to the bathroom to be cleaned. During the process of cleaning of the patient, one PC [program counselor] screamed at the patient in an abusive and aggressive manner without any apparent provocation...[PC #1] pushed the patient more than once in a forceful manner, again without any provocation. The Registered Nurse [RN] and second PC attempted to intervene as best they could while they steadied the patient who had a unsteady gait and was considered a high fall risk...it was determined the PC [#1] acted in an inappropriate and non-therapeutic manner with respect to the patient..."

Interview with the Risk Manager (RM) on 3/8/18 at 12:00 PM, in the RM office, revealed "...the facility initiated an investigation and staff was interviewed...all of the stories matched up and on 10/26/17 we concluded the investigation..."

Telephone interview with PC #2 on 3/8/18 at 1:00 PM revealed the PC was asked to come to the unit to assist with a patient who was in the bathroom, was very aggressive, and loud. Further interview revealed "...[PC #1] had an attitude with the patient the entire time. She went out the room to get wet washcloths and came back into the room making rude comments about the patient smelling and said we could never get her clean because she smelled so bad...when the patient went to the sink she kept telling the patient to wash her hands, to use soap, and was almost yelling at the patient...at one point, the patient asked [named PC #1] why she was yelling at her...[PC #1] was almost up in the patient's face...[PC #1] pushed the patient two or three times with both of her hands...after we took the patient back to her bed [PC #1] just left the room...stated she needed a break..."

Telephone interview with RN #1 on 3/14/18 at 11:35 AM revealed RN #1 was the charge nurse the night of the alleged incident. Further interview revealed "...[Patient #3] was difficult to manage, was known to be very loud, and she wanted to do things for herself...[PC #1] was put out that night that she had to sit with the patient because the patient was a high risk for falls..." Further interview revealed "...[PC #1] went out of the room to get washcloths and then came back and you could tell she was mad...when the patient came around the corner to wash her hands [PC #1] yelled at the patient very loudly 'wash your hands' and stood in the doorway where the patient could not get out of the room...[PC #1] yelled at the patient 'dry your hands' and she put her hands to the patient's shoulder...[PC #1] pushed the patient gently to keep her from going out the door...then pushed the patient again and this time it was harder...[PC #1] was yelling 'throw the towel away'...I thought the patient was going to fall...the patient yelled at [PC #1] 'why are you yelling at me'...even the patient knew [PC #1] was yelling at her...[PC #1] stormed out the room and left the unit without telling me or anyone she was leaving...when [PC #1] came back to the unit she stated 'I know I am in trouble, has anyone called the supervisor yet'..."

Medical record review revealed Patient #4 was admitted to Facility B on 1/3/18 with diagnoses including Suicidal Ideation (SI), Psychotic Disorder, and rule out Bipolar Disorder with Psychotic Feature.

Medical record review of an Admission Psychiatric Assessment dated 1/4/18 at 2:04 PM revealed "...admitted with acute psychosis and SI with a plan to shoot himself. At this time, patient was extremely paranoid and disorganized and sometimes answers the questions and sometimes does not answer the questions. The patient reported that he is hearing voices and these voices are very derogatory in nature...patient started shouting that there are cameras in this room and everybody is following me and watching me...very disorganized..." Further review revealed "...patient reported 'I have been so many places for my pain and mental health problems'...history of SI..."

Review of facility investigation dated 1/9/18 revealed "...the patient was upset over not being able to reach a person by phone. He sat down on the floor and seemed to be gathering thoughts. One PC (#3) informed the patient that he could not sit on the floor and needed to go to the time out room. Instead of going to the time out room the patient instead went back to his bed and covered up in his blanket. Two PC's went to the patient and attempted to remove the patient from his bed. At that time the patient became resistant and the counselors attempted to place him in a physical hold so that he could be escorted to the time out room. During the physical hold and escort the patient became resistant and began to yell and curse. The 2 PC's finally got the patient to the time out room door. From there, one PC [#3] pushed the patient into the time out room with such force that the patient hit the wall opposite of the door...we believe that the PC [#3] that pushed the patient into the time out room used excessive force and that less restrictive measures could have been utilized. Further we believe the behavior by this PC would most likely meet the definition of abuse..."

Review of a facility video and interview with the Chief Nursing Officer (CNO) on 3/8/18 at 2:15 PM, in the Risk Managers office, revealed:
Camera #11 Dated 1/9/18
9:34 AM: the patient was approached by PC #4. The patient got up and went to the bed.
9:35:36 AM: PC #3 approached the Patient #4's bed followed by PC #4. PC #3 tears the blankets off of the patient.
9:36:09 AM: PC #3 and #4 remove the patient from the bed, Patient #4 struggles and the mattress flips off of the bed.
Camera #8 Dated 1/9/18
9:36:53 AM: Patient #4 shoved into the time out room and into the distal wall of the room. Patient #4 regains balance and then sits down against the wall.
9:37:08 AM: Patient #4 attempted to walk to the door.
Interview with the CNO confirmed Patient #4 was pushed into the time out room by PC #3.

Interview with the Nurse Manager on 3/8/17 at 2:30 PM, in the RM office, confirmed "...I reviewed the video footage and completed a time line. Camera #8 revealed the actual footage of the patient being shoved into the room by [PC #3]...we found that the patient was aggressively forced from his bed and escorted to the time out room with excessive physical force and then aggressively shoved into the room causing the patient to fall into the wall...[PC #3] was terminated...related to not following our policy and using excessive force with a patient..."

Interview with PC #4 on 3/8/18 at 2:55 PM, in the RM office, revealed "...the patient was in the floor and had a phone in his hand...he became very upset and [PC #3] asked the patient not to sit in the floor...the patient was agitated, yelling out loud, and cursing at the staff and the other patients...we [PC #3 and PC #4] decided to calm the situation...[PC #3] went to talk with the patient and the patient started banging his hands on the walls at his bed...[PC #3] asked the patient to go to the time out room but the patient refused. He went to his bed and covered himself up...that is when we had to go hands on with the patient...when we approached the patient he became aggressive...we had to wrestle the patient out of the bed and the patient grabbed his mattress and shoved the mattress into the floor...[PC #3 and PC #4] physically had to escort the patient to the time out room and at the door [PC #3] shoved the patient in the room...I did not realize the significance of the shove until they showed me the video..."

Interview with the CNO on 3/8/18 at 3:30 PM, in the RM office, confirmed "...the video itself was conclusive enough for us to make the decision to terminate [PC #3]...we did conclude that he [PC #3] was acting in a demeanor that appeared abusive..."

Telephone interview with PC #3 on 3/13/18 at 9:12 AM revealed "...the patient was yelling and cursing at the staff and we told him he could not do that. I asked the patient to go to the time out room but he refused. We tried to deescalate the patient by talking to him but that did not work..." Further interview confirmed "...the patient was less than cooperative with this...overall it ended up not looking good for me...I did not shove the patient, I just pushed him into room due to the fact he was being so aggressively..."