HospitalInspections.org

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to ensure patient care plans were individualized and revised with problems, goals and interventions that would meet the assessed patient care needs for one (1) of ten (10) sampled patients. (Patient #1)

The findings include:

Review of the facility's policy regarding Treatment Planning Process-Inpatient, dated September 2014, revealed the purpose of the policy was to provide a complete, individualized, plan of care based on the integrated assessment of the patient's specific needs and problems, and prioritization of those needs/problems; to provide appropriate communication between team members that fostered consistency and continuity in the care of the patient; to formulate a plan of care that meets the objectives and needs. Care planning was a process for each patient, whereby an individualized plan would be developed to address the specific issues or problems identified by the patient and staff. Based on assessments of clinical needs, the plan shall describe patient strengths and disabilities; active problems to be addressed; goals and objectives of treatment; clinical interventions prescribed; patient progress in meeting treatment goals and objectives; criteria for termination of treatment; and provision for aftercare. The plan of care would be developed and implemented within seventy-two hours of the patient's admission, approved by the patient and/or guardian and approved by the physician. The care plan would be reviewed and evaluated at scheduled intervals appropriate to the patient's needs and anticipated length of stay. Additional reviews would be completed if there was a change in the patient's condition.

Observation, on 11/19/15 at 8:35 AM, revealed the facility had four classrooms and patients were seated at desks receiving education from teachers. The patients were clean, hair combed and wearing appropriate clothing for the weather. The environment was free from dirt, debris, and clutter. No odors were detected. Observation of the Childrens Unit on, 11/19/15 at 9:15 AM, revealed staff were moving about and all patients were off the unit. A housekeeper was on the unit mopping and wiping down surfaces.

Review of the clinical record for Patient #1 revealed the facility admitted the patient on 09/11/15 with diagnoses of Hydrocephalus, Epilepsy, Cognitive Disorder, Attention Deficit with Hyperactivity disorder and Mood disorder. Further review revealed the patient was born premature and experienced a significant brain bleed after birth. In addition, the patient had a cranial shunt implanted to drain excessive fluid off the brain; which was revised in 2012.

Review of the Psychological Evaluation, dated 09/28/15, revealed Patient #1 had an intelligence quotient (IQ) of sixty-nine (69) which meant the patient's intelligence level was extremely low. (IQ range: Extremely Low- range 69 and below, Superior intelligence- range 130 and above)

Review of the Nursing Admission Assessment, dated 09/11/15, revealed repetitive noise would trigger negative emotions or behaviors. The actions listed on the form to help the patient calm down, were to allow the patient to color, go to their room, have a blanket, or use an I Pad. However, these actions were not listed on the comprehensive plan of care.

Review of the Comprehensive Care Plan for Resident #1 revealed the facility developed a plan of care for anger and aggression on 09/11/15, with updated goals and target dates for 10/02/15. Problems on the care plan stated the patient had anger and aggressive issues. The goal, dated 09/11/15, related to anger stated the patient would not attempt to physically harm others due to anger for three days. However, no interventions were listed that directed staff on how to accomplish the goal. Another goal, dated 09/11/15, stated the patient would comply with medication orders and interventions each shift. The intervention, dated 09/11/15, related to the goal, stated staff would assess, monitor, document and report changes in behavior related to anger and aggression each shift. However, there were no interventions listed that directed staff on how to encourage the patient to take medication without becoming angry or aggressive. Another goal, dated 09/11/15, stated the patient would maintain boundaries with peers and staff and respect the personal space of others each shift. The intervention, dated 09/11/15, related to the goal, stated staff would utilize distraction, verbal de-escalation, or other hospital approved verbal interventions in an effort to decrease negative behaviors. Review of Plan of Care Update/Review form, dated 09/28/15, revealed the patient exhibited anger and aggression. Staff noted the patient continued with irritability and low frustration tolerance, had yelled at peers, hit staff and cursed others. The form noted the patient's goal was not achieved and no change or modification was needed. In addition, no change or modification to the interventions were made even though the goal for anger and aggression had not been met. Review of the Plan of Care Update/Review form, dated 09/30/15, revealed the patient had been agitated and cussing at peers, hit staff and peers. Again the form noted the goal was not met and no additional interventions were added related to anger and aggression behaviors to meet the needs of the patient.

Review of the Nursing note, dated 09/28/15 and timed at 3:35 PM, revealed a nurse choked Patient #1 because he/she would not take his/her medication. The note stated the patient reported difficulty breathing while being choked and denied any aggression or wrong doing.

Interview with Registered Nurse (RN) #1, on 11/20/15 at 4:55 PM, revealed it had been a very chaotic morning on 09/28/15 and she did not have time to review Patient #1's plan of care. She stated she had not taken care of Patient #1 before and did not know the patient was cognitively impaired with an IQ of 69. She stated Patient #1 refused to take his/her medication while on the unit, so she waited and took it to the classroom to administer it. RN #1 stated she spoke with the teacher and requested Patient #1 to come out into the hall to take the medication.

The patient refused to come out into the hall so she went into the classroom. She stated she requested again that the patient take the medication and the patient threw a pencil across the room. RN #1 stated she told the patient she would have to call the mental health workers into the classroom and have them escort the patient out of the room if he/she would not take the medication. She stated she got down closer to the patient's face and asked again and the patient hit her in the side of the head. She stated she grabbed the seated patient around the chest/shoulders and the patient bit her and they struggled at which time her arm then slid up around the patient's neck.

She stated even though staff came into assist and requested her to let go several times, she did not take her arm off the patient's neck. She stated she did not want anyone else in the vicinity to get hurt. She stated in hindsight she should have just walked away when the resident refused the second time and let someone else try to administer the medication. She stated using de-escalation techniques, as directed on Patient #1's plan of care, would have been the appropriate way to handle the situation.

Interview with Registered Nurse #2, on 11/19/15 at 11:25 AM, revealed the plan of care directed staff in the care of the patient. She stated Patient #1's admission assessment stated the patient had explosive anger issues, limited communication skills, and had difficulty accepting direction. She stated the patient did not like loud noises or to be told "no". She stated the patient needed to have a structured routine to prevent anxiety and behaviors. She stated the patient at times would refuse to take medication for her and she would just wait twenty minutes and try again and the patient would take the medication.

She further stated, if an incident occurred the plan of care should be revised with additional interventions to prevent another. She stated they failed to revise the plan of care after the incident on 09/28/15; in addition to ensuring the comprehensive plan of care had the individualized interventions listed on the admission assessment.

Interview with Registered Nurse #3, on 11/20/15 at 12:35 PM, revealed he was called into take over after RN #1 left. He stated he typically worked directly with the patients while on the unit and RN #2 did all the paper work. He stated the plan of care directed the staff in the care of the patient.

He stated he had only heard rumors about what happened between Patient #1 and RN #1 and was not directed to do anything after he assumed care of the patients on the unit. He stated he did not update or revise Patient #1's plan of care. He stated nursing should have revised Patient #1's plan of care to ensure their care needs would be met.

Interview with the Director of Nursing, on 11/20/15 at 12:55 PM, revealed she was new to the role, as of June 2015, and had determined staff needed additional education related to the development and revision of care plans. She stated she had completed an informal audit towards the end of September 2015, in which she reviewed nursing documentation; however, she would not begin the official review process until January 2016 and at that time she had planned on addressing the care plan development and revision more formally with the nursing staff.

She further stated after the incident with RN #1 and Patient #1 she did not direct staff to do anything differently and had not reviewed Patient #1's medical record for completion or to determine if the plan of care had been revised. She stated it was her expectation that staff would ensure care plans were individualized with interventions to meet the patients needs, especially after an incident occurred.

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to ensure processes were in place to ensure contracted staff that had direct contact with patients were screened for possible abuse history. In addition, it was determined the facility failed to ensure staff immediately reported suspected and/or actual cases of abuse, and that all possible witnesses were verbally interviewed, all effected patients were assessed and actions taken were documented to ensure patient safety for one (1) of ten (10) sampled patients. (Patient #1)

The findings include:

Review of the facility's policy regarding Abuse/Neglect Reporting, dated January 2014, revealed the purpose of the policy was to establish guidelines for the timely reporting of possible victims of abuse or neglect using identified criteria. Patients would not be subjected to any form of neglect or abuse by staff, other patients, or visitors while they were a patient at the hospital. The facility would maintain a risk management process that maximized protection of patients, and established procedures for patients who had experienced neglect or abuse in the hospital. Abuse was the willful angry or violent touching of a patient that could, would, or does produce bodily harm. Examples were hitting, kicking, or the harmful restraint of a patient. Behavioral indications of physical abuse included; exhibited sporadic temper tantrums, a short attention span, hyperactive, or needs control of others. All incidents of witnessed or reported abuse/neglect shall be reported to the immediate supervisor or nurse on the unit. In addition, staff would chart activities on behalf of the patient in the medical record and encourage the patient to write a statement. The nurse would notify the house supervisor, physician, appropriate authorities and document all activity on the behalf of the patient. The nurse would conduct an assessment of the patient to determine the presence of physical injury or trauma, secures area/room, and preserves evidence. Photos would be taken of injuries, if indicated, and orders obtained for evaluations or need of increased level of monitoring. Staff would document all activities taken in the patient's medical record. Staff must provide the patient with emotional support. After the initial shock and anxiety, most patients return to normal activities in a few days to few weeks. However, victims may experince sleep disturbances, change in eating habits, fears, phobias, somatic complaints, or irritability.

1. Review of the clinical record for Patient #1 revealed the facility admitted the patient on 09/11/15 with diagnoses of Hydrocephalus, Epilepsy, Cognitive Disorder, Attention Deficit with Hyperactivity disorder and Mood disorder. Further review revealed the patient was born premature and experienced a significant brain bleed after birth. In addition, the patient had a cranial shunt implanted to drain excessive fluid off the brain; which was revised in 2012.

Review of the Psychological Evaluation, dated 09/28/15, revealed Patient #1 had an intelligence quotient (IQ) of sixty-nine (69) which meant the patient's intelligence level was extremely low. (IQ range: Extremely Low- range 69 and below, Superior intelligence- range 130 and above)


Review of Patient #1's Nursing Admission Assessment, dated 09/11/15, revealed repetitive noise would trigger negative emotions and/or behaviors. The actions listed on the form to help the patient calm down, were to allow the patient to color, go to their room, have a blanket, or use an I Pad. However, these actions were not listed on the comprehensive plan of care.


Review of the Comprehensive Care Plan for Resident #1 revealed the facility developed a plan of care for anger and aggression on 09/11/15, with updated goals and target dates for 10/02/15. Problems on the care plan stated the patient had anger and aggressive issues. The goal, dated 09/11/15, related to anger stated the patient would not attempt to physically harm others due to anger for three days. However, no interventions were listed that directed staff on how to accomplish the goal. Another goal, dated 09/11/15, stated the patient would comply with medication orders and interventions each shift. The intervention, dated 09/11/15, related to the goal, stated staff would assess, monitor, document and report changes in behavior related to anger and aggression each shift. However, there were no interventions listed that directed staff on how to encourage the patient to take medication without becoming angry or aggressive. Another goal, dated 09/11/15, stated the patient would maintain boundaries with peers and staff and respect the personal space of others each shift. The intervention, dated 09/11/15, related to the goal, stated staff would utilize distraction, verbal de-escalation, or other hospital approved verbal interventions in an effort to decrease negative behaviors.


Review of Nursing note, dated 09/28/15 and timed at 3:35 PM, revealed a nurse choked Patient #1 because he/she would not take his/her medication. The note stated the patient reported difficulty breathing while being choked and denied any aggression or wrong doing.

Observation, on 11/19/15 at 8:35 AM, revealed the facility had four classrooms and patients were seated at desks receiving education from teachers. The patients were clean, hair combed and wearing appropriate clothing for the weather. The environment was free from dirt, debris, and clutter. No odors were detected. Observation of the Childrens Unit on, 11/19/15 at 9:15 AM, revealed staff were moving about and all patients were off the unit. A housekeeper was on the unit mopping and wiping down surfaces.


Interview with the Teacher, on 11/19/15 at 12:15 PM, revealed Patient #1 was low functioning with a very low IQ. She stated the patient's behavior was normally pretty good in her classroom. She stated RN #1 came to the room to administer Patient #1's medication around 8:45 AM. She stated the nurse requested the patient to come to her and the patient refused to go to the nurse at the door.

The Teacher stated she asked the patient to go to the door and the patient refused again. She stated the nurse came into the room and went over to the patient, while she continued to greet patients at the door. She stated when she turned back around she saw the nurse and the patient in an altercation. She stated she could see the nurse had her arm around the patients neck and was choking him/her. She stated the patient was yelling and crying for the nurse to get off of him/her.

She further stated she hollered for the Mental Health Associates (MHA's) in the hallway to come assist with the incident. She stated after the staff were able to get the two apart the nurse left the room and the MHA's spoke with the patient. She stated they took the patient out of the room for few minutes and then the patient returned to the classroom and remained until class ended.

She stated she reported the incident to her principal and wrote a statement sometime later that day regarding what she had seen. She stated she did not report the incident to the facility management because she believed the staff that assisted with the altercation had reported the incident to the facility supervisor.


Interview with Mental Health Associate (MHA) #1, on 11/19/15 at 8:37 AM, revealed on the morning of 09/28/15 she was working on the Childrens Unit with Registered Nurse (RN) #1. She stated it was very chaotic that day and the patients were acting out. She stated she witnessed RN #1 yell at the children on the unit in a threatening tone, around 7:30 AM on 09/28/15. She related RN #1 told the patient's to shut up or she would give them all a shot.

She further stated to her, this was a threatening statement and considered verbal abuse. She stated it was not their job to scare the patients in to behaving a certain way. She stated she did not report this behavior or statement made to the supervisor because they were not in the building yet. She stated she had access to the supervisor's contact number; however, she did not use it and decided to wait until they came in to report the incident.

She stated later she was outside the classroom when Registered Nurse #1 came to administer medication to Patient #1. She stated within a few minutes the teacher asked for her assistance. She went into the classroom and saw RN #1 with her arm around Patient #1's neck. She stated the patient was screaming that the nurse was choking him/her. She had to tell the nurse three times to let go of the patient before the nurse would let the patient go. Patient #1 told her the nurse also punched him/her during the altercation.

MHA #1 stated in her opinion she believed Registered Nurse #1 took Patient #1's behavior personally and reacted. She stated she reported the incident to the supervisor, but could not remember the time she reported it to her. She stated she was required to report immediately any witnessed or suspected abuse to her supervisor. She stated reporting abuse timely ensured patient safety.

Interview with Registered Nurse (RN) #1 on, 11/20/15 at 4:55 PM, revealed she was a new employee and new to psychiatric nursing. She stated it had been a very chaotic morning on 09/28/15 and she did not have time to review Patient #1's plan of care. She stated she had not taken care of Patient #1 before and did not know the patient was cognitively impaired with an IQ of 69.

She related Patient #1 refused to take his/her medication while on the unit, so she waited and took it to the classroom to administer the medication sometime after 8:00 AM. RN #1 stated she spoke with the teacher and requested for Patient #1 to come out into the hall to take the medication. The patient refused to come out into the hall so she went into the classroom. She stated she requested again that the patient take the medication and the patient threw a pencil across the room.

RN #1 stated she told the patient she would have to call the mental health workers into the classroom and have them escort the patient out of the room if he/she would not take the medication. She stated she got down closer to the patient's face and then asked again and the patient hit her in the side of the head. She stated she grabbed the seated patient around the chest/shoulders and the patient bit her and they struggled at which time her arm then slid up around the patient's neck.

She further stated even though staff came into assist and requested her to let go several times, she did not take her arm off the patient's neck. She stated she did not want anyone else in the vicinity to get hurt. She stated in hindsight she should have just walked away when the resident refused the second time and let someone else try to administer the medication. She stated using de-escalation techniques, would have been the appropriate way to handle the situation.

RN #1 stated after the incident one of the Mental Health Associate's brought Patient #1 out into the hallway and she spoke with the patient and administered the medication and the patient returned to the classroom. She stated she went to the unit and told the Unit Manager she needed to speak with her about an incident. The Unit Manager said she was busy and it would have to wait. She continued to provide care to patients and she did draw up medications to give, but she could not remember if it was for Patient #1 or another patient.

She stated about thirty (30) to forty-five (45) minutes later the Unit Manager (UM) came to her and said she had heard a rumor that she had choked Patient #1. She stated at that time she discussed the incident with the UM and had her write a statement and she left the building sometime after 10:00 AM.

Interview with Registered Nurse (RN) #2, on 11/19/15 at 11:25 AM, revealed she had also worked the Children's unit on 09/28/15. She stated RN #1 was new to the facility and would get easily frustrated. RN #2 stated she was busy and behind schedule that morning. She stated the patient's were acting out, bickering and wanted to fight around 7:30 AM.

RN #2 stated she did not hear RN #1 make a statement to the patient's to shut up or she would give them a shot. She stated no one reported to her that RN #1 had made that comment either. She stated that was not an appropriate comment and could be verbal abuse; which should be reported immediately.

She stated that morning Patient #1 did not want to take his/her medication from Registered Nurse #1 and she told RN #1 to just wait and give it later. She stated RN #1 had not worked with Patient #1 and did not know the patient would refuse medication at times and that you would have to wait and try again later.

She stated the patients went to their classrooms, that were off the unit, around 8:00 AM. She stated later in the morning she witnessed RN #1 drawing up a syringe of medication and she asked who the medication was for, and RN #1 stated Patient #1 had hit her and she was going to give the patient an injection.

She stated the patient was not on the unit at this time and believed the patient was still in the classroom. She stated she did not know the details of the incident at that time; however, a little while later Mental Health Associate (MHA) #1 told her she witnessed RN #1 with her arm around Patient #1's neck, choking him/her in the classroom.

RN #2 stated she told the MHA she needed to report what she had seen to the Unit Manager. She stated since she had not witnessed the event she was not required to report what she was told and it was ultimately the responsibility of the MHA to report it.


Interview with the Unit Manager (UM), on 11/19/15 at 10:10 AM, revealed she did not recall much about the details of her actions taken on the day of 09/28/15. She stated her role as the Unit Manager in suspected cases of abuse was to gather the facts, keep the patient safe and send the perpetrator home.

She stated Registered Nurse (RN) #1 came to her sometime the morning of 09/28/15 and told her Patient #1 had punched her in the face. She stated RN #1 told her she reacted after being punched in the face, by putting her arms around the patient and in the struggle RN #1's arm came up around the patient's neck and she choked the patient.

She stated RN #1 told her the incident must have looked bad to others. The UM stated she did not think Mental Health Associate (MHA) #1 had reported the incident to her. She stated she did not interview MHA #1 or other potential witness about the incident. She stated she had only collected their written statements.

The UM stated she did not document her actions taken nor had she made a written report of her conclusions from her fact finding. She stated everything she did was performed verbally. She stated she informed the Director of Nursing (DON) the incident occurred; and the DON did not direct her to do anything additional.

She stated sometime later she was directed by the Compliance Officer to make a late entry into Patient #1's medical record that the incident occurred; because she had forgotten to. She stated she did not make any determinations or conclusions from her fact finding activities and that management was responsible for conducting any follow up actions.


Interview with the Director of Nursing, on 11/20/15 at 12:55 PM, revealed it was probably around 10:00 AM on 09/28/15, when the Unit Manager (UM) made her aware of the incident with Patient #1. She stated the UM started the investigation and the Compliance Officer (CO) and the Chief Operating Officer (COO) were making the appropriate notifications to the authorities.

She stated she did not direct the UM to do anything additional and she did not conduct any portion of the investigation. She stated later she heard the CO and COO had met with Registered Nurse #1 and she was terminated for not following policy. She stated she was verbally provided information about the actions taken by others, and did not receive a written report of the findings or conclusion of the investigation. She stated an opportunity for improvement related to physical management techniques was the only determination that was made from the incident.

However, no action plan had been put in place as of yet. She stated prior to the incident the UM had been placed on a performance improvement plan related to her inability to manage the unit according to expectations. She stated even with this knowledge she believed the UM had the skills and knowledge to conduct an investigation according to hospital policy. She stated she did not know the UM had not interviewed the witnesses or patients to determine the sequence and facts of the event. She stated her role in an incident/abuse investigation was to guide the staff in the process and manage the direct aspects of it.

She stated she was not aware staff had not physically and emotionally assessed the patient or others affected. She stated she did not know staff failed to document their actions taken as per their abuse policy. The DON stated MHA #1 should have immediately reported the witnessed suspected verbal abuse, made by RN #1, at the beginning of the shift on 09/28/15.

She stated the investigation into the incident in the classroom should have been thoroughly investigated to determine all the opportunities for improvement to ensure actions were put in place to prevent a situation like that from happening again. She stated in order to provide safe quality care, staff should have followed the abuse policy guidelines.


Interview with the Compliance Officer (CO), on 11/19/15 at 9:55 AM, revealed the Unit Manager (UM) notified her on 09/28/15 about a suspected incident of abuse. She stated the UM conducted the investigation into the incident and sent the nurse home. She stated Registered Nurse (RN) #1 returned on 09/30/15, to discuss the incident with her and the Chief Operating Officer.

The CO stated it was determined from their conversation that RN #1 went to the classroom to administer Patient #1 their medication and the patient refused to take the medication, threw a pencil across the room and cursed at the nurse. She stated then the nurse proceeded to get closer to the patient and ask the patient to take the medication one more time; and the patient hit the nurse in the head. She stated the nurse then grabbed the patient around the shoulders and her arm slid up and around the patient's neck.

She further stated they believed the nurse reacted with an adrenaline rush and due to her not following policy she was terminated. She stated the teacher's written statement stated she requested staff assistance from the Mental Health Associates (MHA) in the hallway when the altercation began. She stated according to the MHA's written statements they had to ask the nurse three times to let go of the patient.

The CO stated she had reviewed Patient #1's chart and determined the Unit Manager (UM) had not documented the incident in the medical record, so she notified the UM to make a note in the chart on 09/28/15. However, her review did not determine the staff had not assessed and documented the patient's physical and emotional status after the incident, or that the plan of care was not revised.

She stated she was not aware of MHA #1's witnessed account of RN #1 telling the patient's on the Childrens Unit to shut up or she would give them a shot. She stated MHA #1 should have immediately reported the situation to the supervisor so actions could have been taken to address the behavior. She stated it was unacceptable to make that type of comment to the patients.

She further stated it looked like the facility had additional opportunities for improvement related to their abuse reporting and investigation process. She stated if staff did not follow the requirements of the policy, then the patient's needs would not be met.


2. Review of five employee files, on 11/19/15 at 12:15 PM, revealed the facility did not have a file on the Teacher. The facility did not provide evidence of a criminal background check or abuse check for the teacher to ensure they had been conducted prior to allowing the teacher contact with the patients.

Interview with the Compliance Officer, on 11/20/15 at 3:30 PM, revealed she had not read the contract the facility had with the school board and was not sure if the contract directed the school board to conduct an abuse check on the teachers or not. She stated the school board kept the teacher's file containing the criminal background check; however their request for the file had not been answered.

Interview with Human Resources, on 11/20/15 at 2:45 PM, revealed the facility did not conduct their own abuse checks on the contracted teachers. He stated he did not know what the facility contract required the school board to do related to background checks. He stated it was the responsibility of the facility to ensure the contracted staff would be free from abuse history prior to having contact with their patients in the facility.

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to ensure nursing assessed a patient after an incident occurred to ensure the patient care needs were met for one (1) of ten (10) sampled patients. (Patient #1)

The finding include:

Review of the facility's policy regarding Plan for Providing Nursing Care, dated January 2014, revealed psychiatric nursing was a process through which nursing assessed, diagnosed, planned, intervened, and evaluated to assist patients to enhance more positive self-concepts, more harmonious patterns of interpersonal relationships and more productive roles in society. Clinical observations of the patient should be utilized to determine needs and problems and to set appropriate goals and treatment strategies for each patient. The emotional status, thought patterns, and behavioral stress of the patient would be assessed. Clinical observations would be shared and validated with appropriate others. The Admission note would record concise evaluation of the patient and would serve as a baseline for the treatment team.

Review of the facility's policy regarding Managing the Medically Compromised Patient, dated April 2014, revealed for early detection nursing would complete a nursing assessment which included a system review, pain assessment, and a functional screen. In addition, nursing would assess the patient for a history of or current medical risk factors/conditions and would initiate precautions for the conditions.

Review of the facility's policy regarding Abuse/Neglect Reporting, dated January 2014, revealed the purpose of the policy was to establish guidelines for the timely reporting of possible victims of abuse or neglect using identified criteria. Patients would not be subjected to any form of neglect or abuse by staff, other patients, or visitors while they were a patient at the hospital. The facility would maintain a risk management process that maximized protection of patient and established procedures for patient who had experienced neglect or abuse in the hospital. Abuse was the willful angry or violent touching of a patient that could, would, or does produce bodily harm. Examples were hitting, kicking, or the harmful restraint of a patient. All incidents of witnessed or reported abuse/neglect shall be reported to the immediate supervisor or nurse on the unit. The nurse would notify the house supervisor, physician, appropriate authorities and documents all activity on the behalf of the patient. The nurse would conduct an assessment of the patient to determine the presence of physical injury or trauma, secures the area/room, and preserves evidence. Photos would be taken of injuries, if indicated, and orders obtained for evaluations or need of increased level of monitoring. Staff would document all activities taken in the patient's medical record.

Review of the clinical record for Patient #1 revealed the facility admitted the patient on 09/11/15 with diagnoses of Hydrocephalus, Epilepsy, Cognitive Disorder, Attention Deficit with Hyperactivity disorder and Mood disorder. Further review revealed the patient was born premature and experience a significant brain bleed after birth. In addition, the patient had a cranial shunt implanted to drain excessive fluid off the brain; which recently was revised in 2012.

Review of the Psychological Evaluation, dated 09/28/15, revealed Patient #1 had an inelegance quotient (IQ) of sixty-nine (69) which meant the patient's intelligence level was extremely low. (IQ range: Extremely Low- range 69 and below, Superior intelligence- range 130 and above)


Review of the Nursing note, dated 09/28/15 and timed at 3:35 PM, revealed a nurse choked Patient #1 because he/she would not take his/her medication. The note stated the patient reported difficulty breathing while being choked and denied any aggression or wrong doing.

Review of the Psychiatrist Daily Progress Notes, dated 09/28/15 and 09/29/15, revealed no documentation regarding the physical altercation between staff and Patient #1. The documents noted Patient #1 was cooperative, mood and thought processes were with in normal limits. The physical and medical review was left blank. In addition, the form noted the patient was compliant with medication administration.

Review of the Nursing Daily Progress Note, dated 09/28/15 for the 7:00 AM to 3:00 PM shift, revealed the patient was complaint with medication administration, irritable and easily frustrated, but would accept staff redirection. However, there was no documentation regarding a physical assessment of the resident after the altercation in the classroom.

Observation, on 11/19/15 at 8:35 AM, revealed the facility had four classrooms and patients were seated at desks receiving education from teachers. The patients were clean, hair combed and wearing appropriate clothing for the weather. The environment was free from dirt, debris, and clutter. No odors were detected. Observation of the Childrens Unit on, 11/19/15 at 9:15 AM, revealed staff were moving about and all patients were off the unit. A housekeeper was on the unit mopping and wiping down surfaces.

Interview, on 11/20/15 at 4:55 PM, with Registered Nurse (RN) #1, revealed Patient #1 refused to take his/her medication while on the unit, so she waited and took it to the classroom to administer it. RN #1 stated she spoke with the teacher and requested for Patient #1 to come out into the hall to take the medication. The patient refused to come out into the hall so she went into the classroom. She stated she requested again that the patient take the medication and the patient threw a pencil across the room.

RN #1 stated she told the patient she would have to call the mental health workers into the classroom and have them escort the patient out of the room if he/she would not take the medication. She stated she got down closer to the patient's face and then asked again and the patient hit her in the side of the head. She stated she grabbed the seated patient around the chest/shoulders and the patient bit her and they struggled at which time her arm then slid up around the patient's neck. She stated the patient verbally said she was choking him/her during the altercation.

She stated even though staff came into assist and requested her to let go several times, she did not take her arm off the patient's neck. She stated she did not want anyone else in the vicinity to get hurt. She stated in hindsight she should have just walked away when the resident refused the second time and let someone else try to administer the medication.

Interview with Registered Nurse #2, on 11/19/15 at 11:25 AM, revealed she had also worked on the Childrens Unit on 09/28/15. She stated Mental Health Associate #1 had told her that RN #1 had put her arm around Patient #1's neck and choked him/her after the patient had hit her.

She stated she did not go to the classroom to assess the patient and the Unit Manager did not instruct her to assess or monitor the patient for potential physical or emotional injury from the incident. She stated nursing should have assessed the patient for signs of physical and emotional harm and documented the findings in the medical record.


Interview, on 11/20/15 at 12:35 PM, with Registered Nurse (RN) #3, revealed he was called in to work on the Childrens Unit after RN #1 left. He stated he typically worked directly with the patients while on the unit and RN #2 did all the paper work and this arrangement occurred on 09/28/15. He stated he had only heard rumors about what happened between Patient #1 and RN #1.

He stated he did not get a report regarding what happened or what had been completed for Patient #1. He stated he was not directed by the Unit Manager nor RN #2 to assess Patient #1 or that there was a need to monitor further for harm or change in condition after he arrived on the unit. He stated while out on the unit he over heard other patients, that witnessed the incident, make remarks; he stated the patient's were upset and concerned about the situation that happened in the classroom. He stated he directed the patients to not talk about it and change the subject.

He stated normally after an altercation nursing would assess the patient. He stated the assessment would include vital signs, physical head to toe assessment, to look for bruising or other injuries. He stated in addition, they would verbally process the situation with the patient to determine their emotional status. He stated that should have been completed with Patient #1 in order to ensure their emotional and physical needs were met.


Interview with the Unit Manager, on 11/19/15 at 10:10 AM, revealed she did not direct nursing staff to assess Patient #1 after the altercation with RN #1. She stated Patient #1 remained in the classroom after the incident and she assumed RN #1's role on the unit, until another nurse came in. She stated she did not obtain Patient #1's vitals or perform a full head to toe assessment of the patient after the incident. She stated her role was to gather the facts of the incident from the witnesses and that was her main focus.


Interview, on 11/20/15 at 12:55 PM, with the Director of Nursing revealed she was new to the role, as of June 2015. She stated she believed the nursing staff had assessed Patient #1. She stated she had not reviewed the medical record for completeness after the incident occurred on 09/28/15; and did not know nursing staff had not documented a physical or emotional assessment of Patient #1.

She stated it was her expectation that staff would conduct a nursing assessment on a patient involved in a physical altercation. She stated she received a verbal report from the Unit Manager regarding the incident the morning of 09/28/15; however, she did not direct the Unit Manager to ensure the patient had been assessed and that documentation of actions taken were completed. She stated if the patient was not assessed physically and emotionally after an incident the patient needs would not be met.

Interview with the Compliance Officer, on 11/19/15 at 9:55 AM, revealed she had reviewed Patient #1's medical record and identified staff had not documented information regarding the incident in the record. She stated she directed the Unit Manger to make a late entry into the record about the incident.

However, she had not identified nursing had not assessed the patient after the incident nor had the team updated the plan of care to direct staff on further actions. She stated it was important to assess the patient's physical and emotional needs after an incident to ensure actions were taken to meet the patient's ongoing needs.