HospitalInspections.org

Based on interview, record review, policy review and video recording review, the hospital failed to provide a safe environment, free from abuse, when they failed to:
- Activate "Dr. Ryan," (notification to the entire hospital for assistance from the Crisis Intervention Team and Security Department to aid in de-escalating potentially dangerous patient behaviors) when Patient #4's behavior escalated (A-0144).
- Recognize that Staff K, Registered Nurse (RN), and Staff L, RN, used non-approved Crisis Prevention Institute (CPI, a type of training whereby staff use physical holds which restrict a person's movement) techniques, which resulted in the abuse of Patient #4 (A-0144).
- Provide immediate re-education of approved CPI techniques to Staff K and Staff L, to prevent re-occurrences of use of unapproved CPI techniques (A-0144).
- Complete a thorough investigation, when Staff K and Staff L were alleged to have abused Patient #4 (A-0145).

These deficient practices resulted in the hospital's non-compliance with specific requirements found under the Condition of Participation: Patient's Rights. The hospital census was 36.

The severity and cumulative effect of these practices had the potential to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ).

On 03/03/20, after the survey team informed the hospital of the IJ, the staff created educational tools and began educating all staff and put into place interventions to protect the patients.

As of 03/05/20, at the time of the survey exit, the hospital had provided an immediate action plan sufficient to remove the IJ by implementing the following:
- The staff members involved in the staff to patient abuse incident have been terminated from the hospital.
- All patient care staff members and security team members were given scenario based education which included the understanding of Patient's Rights, Abuse and Neglect, Dr. Ryan Criteria and proper Crisis Prevention Institute (CPI, a type of training whereby staff use physical holds which restrict a persons movement) techniques.
- Nursing Staff, including the Chief Nursing Officer (CNO) and Director of Nursing, will undergo training to identify and distinguish events that were reportable, and on the hospital's policies and protocols for initiating and investigating reportable events.
- The certified CPI instructor and security will be included in all reviews of alleged abuse and neglect videos. They will provide debriefing and analysis to hospital management in proper investigation protocols for responding to reports of suspected, potential or actual abuse.
- On 12/31/19, Americore Holdings, LLC filed Chapter 11 Bankruptcy protection in the United States Bankruptcy Court for the Eastern District of Kentucky. Americore Holdings, LLC, is the parent company of St. Alexius Hospital. On 02/21/20, Carol Fox was appointed Chapter 11 Trustee by acting U.S. Trustee Paul A. Randolph, and assumed management of the hospital's operations. On 02/26/19, Ms. Fox engaged GlassRatner Advisory & Capital Group, LLC (GlassRatner) as financial consultants. Members of the GlassRatner team have extensive healthcare compliance experience. The team will immediately include in their focus the patient quality and safety issues identified through this event and will provide analysis and advice to maintain and strengthen best practices for patient quality and safety throughout the hospital.
- To further monitor the quality of care provided to patients, the hospital will fully engage the Patient Care Ombudsman (PCO, someone appointed to monitor the quality of patient care provided and report such care to the court) appointed by the U.S. Trustee's Office.

Based on observation, interview, record review, policy review and surveillance video recording review, the hospital failed to provide a safe environment for one current patient (#4) of one allegation of staff to patient abuse reviewed, when they failed to:
- Activate "Dr. Ryan," (notification to the entire hospital for assistance from the Crisis Intervention Team and Security Department to aid in de-escalating potentially dangerous patient behaviors) when Patient #4's behavior escalated.
- Recognize that Staff K, Registered Nurse (RN), and Staff L, RN, used non-approved Crisis Prevention Institute (CPI, a type of training whereby staff use physical holds which restrict a person's movement) techniques, which resulted in the abuse of Patient #4.
- Provide immediate re-education of approved CPI techniques to Staff K, RN, and Staff L, RN, to prevent re-occurrences of use of unapproved CPI techniques.
These failed practices had the potential to create an unsafe environment for all patients admitted to the hospital seeking care and treatment. The hospital census was 36 and the census on the 3rd floor Acute Psychiatric Female Unit was 12.

Findings included:

1. Review of the hospital's policy titled, "Patient Rights and Responsibilities," dated 05/2019, showed that patients are to be cared for in a safe environment, free from all abuse.

Review of the hospital's policy titled, "Abuse and Neglect," dated 07/2019, showed that abuse is the infliction of physical, verbal or emotional injury or harm by another person.

Review of the hospital's policy titled, "Dr. Ryan," dated 06/2019, showed:
- Available hospital employees that have been trained in CPI, Manager of the department where the incident occurs or House Supervisor, and security personnel will respond when a Dr. Ryan is called.
- If physical intervention is required to assure safety, the Primary Nurse or designee will direct staff as follows, utilize team control position as instructed in CPI; designate a nursing staff to prepare and have ready an as needed medication; and assign one staff to prepare the seclusion room if necessary.
- CPI interventions shall be utilized by staff when attempting to manage a patient during a "Dr. Ryan".

Review of Patient #4's medical record showed that the patient was admitted to the hospital's 3rd floor Acute Psychiatric Female Unit on 02/11/20, with complaints of self-harming behavior and suicidal ideation (SI, thoughts of causing one's own death). The patient was placed on suicide precautions (SP, interventions put into place to prevent self-harm or death), assault precautions (AP, alerts staff that a patient is potentially a danger to others) and close observation (the act of watching a patient carefully, reporting and documenting what is seen, noticed or abnormal).

During an interview on 03/02/20 at 3:10 PM, Patient #4 stated that:
- The previous week, an incident occurred with two nurses, where one nurse was "mean" to her because she would not leave her room door open.
- She "spit" in one of the nurse's face and in return the nurse "spit" in her face, put her hands around the patient's neck and "choked" the patient for approximately one minute.
- One of the nurses kept telling the patient to say that she was "sorry" and to say it like she meant it.

Review of the hospital's internal investigation showed:
- An email dated 02/24/20 at 8:31 AM, written by Staff JJ, Nursing Supervisor, showed that Patient #8, roommate of Patient #4, reported that she saw Staff L, RN, and Staff K, RN, push Patient #4 down onto her bed mattress two times. Staff L spit on and slapped Patient #4. Staff L had Staff K shut the door to their room, then Staff L put her hands around Patient #4's neck, choked the patient and told her to say she was "sorry" like she meant it.
- Documentation from Patient #4's written statement showed that the nurse pushed the patient down onto her mattress twice. The patient spit on the one nurse who in return spit back at the patient. The other nurse "choked" her so hard that she was not able to breathe. The nurse kept repeating for her to say that she was sorry but the patient could not say she was sorry because the staff had her choked so tightly that she could not breathe. More staff arrived and the patient went to the "quiet room," (a non-stimulating room used for patients that display aggressive, threatening or disruptive behaviors in an attempt to calm the patient and alleviate the behaviors).
- Review of an email dated 02/25/20 at 11:54 AM, written by Staff M, Chief Nursing Officer (CNO), showed that after she and Staff J, RN, Acute Psychiatric 3rd Floor Unit Manager, had reviewed the surveillance video recording and staff and patient interviews, they both agreed that the report was not substantiated.

2. Review of the surveillance video recording dated 02/23/20 showed that:
- Patient #4 closed the door to her room, and when Staff K and Staff L observed her, they attempted to open the door while the patient pushed against it (per interviews, staff should have called a Dr. Ryan when the patient tried to prevent staff from entering her room).
- When it opened, the patient lunged towards and pushed against Staff K.
- Staff K grabbed both of the patient's upper arms and forcefully shoved the patient backwards.
- The patient turned her head towards Staff K and spit in her face.
- Staff K shoved the patient forcefully backwards and appeared to strike the right lower side of the patient's face, jaw and neck with her opened hand.
- Staff K and Staff L then forcefully shoved the patient backwards and the patient appeared to fall backwards and out of view of the video.
- When the patient came back into view, and attempted to stand up, Staff L and Staff K took hold of the patient's arms, and the patient lunged forward.
- Staff L then grabbed the back of the patient's gown, and forcefully pulled the patient backwards.
- Staff K took the patient's arm and raised it above the patient's head, then forcefully shoved the patient's right arm backward behind the patient, and continued to forcefully shove the patient backwards. Staff L also appeared to forcefully shove the patient backwards until the patient fell and Staff K fell down with the patient.
- Staff II, Patient Care Technician (PCT) stopped at the patient's doorway, peered into the room and appeared to say something, then stepped out of the doorway and proceeded down the hall.
- Staff K came back into view, closed the door with the patient, Staff K, Staff L and the roommate in the room (the door remained closed with staff inside for approximately two minutes).

During a telephone interview on 03/10/20 at 3:28 PM, Staff II, PCT, stated that:
- When she was doing rounds for the unit, she stopped by Patient #4's room and she observed the patient on the mattress with Staff K, RN, on top of the patient.
- When she asked staff if they were "ok", both Staff K and Staff L stated yes, so she exited the area.
- When she later returned, one of the nurses asked her to call a "Dr. Ryan".

During a telephone interview on 03/03/20 at 9:00 AM, Staff H, CPI Instructor/Security stated that:
- Staff K did not use approved CPI techniques when she used an opened hand and struck the patient's face, jaw and neck, or when she grabbed the patient's arm and threw the patient onto the mattress.
- It was not appropriate for Staff K to close the door to Patient #4's room especially during an altercation between staff and a patient.
- He voiced his concerns of what he observed on the surveillance video recording to his supervisor, Staff I, Director of Security.
- Staff K had a history of being rough with patients in the past and this was not her first incident.
- He was concerned for patients' safety when Staff K cared for them.
- Staff K was required to receive additional CPI training in the past.

During an interview on 03/03/20 at 9:25 AM, Staff I, Director of Security, stated that:
- He was asked by Staff H, CPI Instructor/Security to view the surveillance video recording because Staff H had concerns with staffs' interactions with the patient.
- The actions by Staff K and Staff L were not approved CPI techniques and was considered abuse.
- It appeared that one of the nurse's hands was raised and hit the patient's face.
- One nurse was observed to grab the patient's arm and pushed it backwards.
- Staff should not close the door to the room because it looked suspicious when staff and a patient were engaged in an altercation.
- The two nurses should have stopped their interactions with the patient when the patient barricaded herself against the door, and at that point staff needed to call a "Dr. Ryan".
- He had reported concerns with Staff K, RN previously.
- Neither Staff K, Staff L, nor other staff on the unit called for a "Dr. Ryan".

3. During an interview on 03/03/20 at 10:10 AM, Staff J, RN, Acute Psychiatric 3rd Floor Unit Manager, stated that:
- Both Staff K and Staff L failed to use approved CPI techniques when they pushed the patient backwards and when staff placed their opened hand towards the patient's face.
- Staff needed to call a "Dr. Ryan" and wait for the CPI team to arrive before the interactions between Staff K, Staff L and the patient escalated.
- Acknowledged that both Staff K's and Staff L's actions towards Patient #4 was "rough."
- Staff K and Staff L needed to remove themselves from the environment and provided both the patient and staff a time to calm down.
- Staff should never close the door to a patient's room when dealing with an aggressive patient.
- She and Staff M, CNO, determined that the allegations of patient abuse were unsubstantiated.
- She provided Staff K and Staff L verbal education on when to call a "Dr. Ryan" and to never close the door with an aggressive patient (formal CPI retraining for Staff K and Staff L was not mentioned)

During an interview on 03/03/20 at 10:45 AM, Staff K, RN, stated that:
- Staff were expected to call a "Dr. Ryan" when a patient began to escalate.
- She acknowledged she used non-approved CPI techniques.
- During review of the surveillance video recording, stated that her actions with the patient appeared rough, she was "surprised" and "shocked" at her actions, and that she could have harmed the patient by forcefully pushing the patient's arm backwards.
- Acknowledged that "hitting" or "slapping" a patient on the face was abuse.
- When she returned to work, the only education she received was to call a "Dr. Ryan" sooner (formal CPI retraining was not mentioned).


During an interview on 03/03/20 at 11:15 AM, Staff L, RN, stated that:
- A "Dr. Ryan" needed to be called before the patient escalated, but it did not appear that a "Dr. Ryan" was called.
- Acknowledged that an opened hand from staff came into contact with the patient's lower face, jaw and neck, and it was not an approved CPI technique.
- Pushing a patient's arm backwards was not an approved CPI technique.
- She looked to Staff K for guidance for dealing with Patient #4's aggressive, threatening and disruptive behaviors since Staff K was the "senior" nurse on the unit.
- Some actions by her and Staff K were a "little strong" and that staff needed to give the patient a "time out" to allow for her to calm down.
- She received verbal education on therapeutic holds from the nurse manager when she returned to work (formal CPI retraining was not mentioned).

During an interview on 03/03/20 at 12:05 PM, Staff M, CNO, stated that:
- After review of the surveillance video, her concerns were that staff almost immediately had hands on the patient, staff did not call for a "Dr. Ryan," and the door to the patient's room was closed by Staff K.
- Based on Patient #4's and Patient #8's (roommate) manipulative behaviors, she believed the allegations of staff abuse towards Patient #4 were not confirmed.
- She reviewed the surveillance video recording, and had reviewed it with various staff, and that all staff that she reviewed the surveillance video recording with agreed that neither Staff K nor Staff L had physically abused the patient.
- She asked Staff J, Acute Psychiatric 3rd Floor Unit Manager, to give Staff K and Staff L refresher education, but was unsure if Staff J had completed the education with Staff K and Staff L.

During an interview on 03/03/20 at 2:05 PM, Staff N, Quality Risk Specialist, stated that:
- When she reviewed the video, Staff K and Staff L did not use approved CPI techniques.
- She had concerns with the amount of force used to push the patient's arm backwards, and that it was more aggressive than staff needed to be with the patient.
- One of the nurse's open hand came into contact with the patient's lower face, jaw and neck, and that type of contact from staff towards a patient was a concern.
- Hitting, shoving or pointing a finger were examples of patient abuse.
- She had concerns that staff failed to call a "Dr. Ryan" when the patient began to escalate.
- She had viewed the surveillance video recording with Staff J, RN, Acute Psychiatric 3rd Floor Unit Manager, and Staff M, RN, CNO, and it was recommended that both Staff K and Staff L needed to repeat CPI training/education.

During an interview on 03/04/20 at 8:30 AM, Staff P, Risk Manager, stated that:
- After she had reviewed the surveillance video recording she requested for Staff H, CPI Instructor/Security, to view the video to determine whether or not Staff K, RN, and Staff L, RN, had used approved CPI techniques.
- She requested Staff I, Director of Security, to review the surveillance video recording to confirm if Staff K and Staff L had abused Patient #4 during their interactions with the patient.
- When she reported her concerns of patient abuse to Staff M, CNO, Staff M informed her that the investigation was completed and closed.

The hospital failed to activate "Dr. Ryan," when Patient #4's behavior escalated, failed to recognize abuse and failed provide immediate re-education of approved CPI techniques before allowing Staff K and Staff L to return to work and provide patient care.

Based on interview, record review, policy review and surveillance video recording review, the hospital failed to complete a thorough investigation, when two staff (Staff K, Registered Nurse (RN) and Staff L, RN) were alleged to have abused one current patient (#4), of one abuse allegation reviewed. This failure had the potential to place all patients at increased risk for their safety and health. The hospital census was 36, and the 3rd floor Acute Psychiatric Female Unit census was 12.

Findings included:

Review of the hospital's policy titled, "Abuse and Neglect," dated 07/2019, showed that abuse is the infliction of physical, sexual, verbal or emotional injury or harm by another person. The Director of Quality Risk Management (DQRM) or designee is responsible for investigating abuse of an inpatient.

Review of Patient #4's medical record showed that the patient was admitted to the hospital's 3rd floor Acute Psychiatric Female Unit on 02/11/20, with complaints of self-harming behavior and suicidal ideation (SI, thoughts of causing one's own death). The patient was placed on suicide precautions (SP, interventions put into place to prevent self-harm or death), assault precautions (AP, alerts staff that a patient is potentially a danger to others) and close observation (the act of watching a patient carefully, reporting and documenting what is seen, noticed or abnormal).

During an interview on 03/02/20 at 3:10 PM, Patient #4 stated that:
- The previous week, an incident occurred with two nurses, where one nurse was "mean" to her because she would not leave her room door open.
- She "spit" in one of the nurse's face and in return the nurse "spit" in her face, put her hands around the patient's neck and "choked" the patient for approximately one minute.
- One of the nurses kept telling the patient to say that she was "sorry" and to say it like she meant it.
- She did not report this incident with the nurse because she was afraid that staff would retaliate against her.

Review of the hospital's internal investigation showed:
- An email dated 02/24/20 at 8:31 AM, written by Staff JJ, RN, Nursing Supervisor, showed that Patient #8, roommate of Patient #4, reported that she saw Staff L, RN, and Staff K, RN, push Patient #4 down onto her mattress twice. Staff L spit on and slapped Patient #4. Staff L had Staff K shut the door to their room, then Staff L put her hands around Patient #4's neck, choked the patient, and told her to say she was "sorry" like she meant it.
- Documentation from Patient #4's written statement showed that the nurse pushed the patient down onto her mattress twice. The patient spit on the one nurse who in return spit back at the patient. The other nurse "choked" her so hard that she was not able to breathe. The nurse kept repeating for her to say that she was sorry but the patient could not say she was sorry because the staff had her choked so tightly that she could not breathe.
- Review of an email dated 02/25/20 at 11:54 AM, written by Staff M, Chief Nursing Officer (CNO), showed that after she and Staff J, RN, Acute Psychiatric 3rd Floor Unit Manager, had reviewed the surveillance video recording and staff and patient interviews, they both agreed that the report was not substantiated.

Review of the surveillance video recording dated 02/23/20 showed that:
- Patient #4 closed the door to her room, and when Staff K and Staff L observed her, they attempted to open the door while the patient pushed against it.
- When the door opened, the patient lunged towards and pushed against Staff K.
- Staff K grabbed both of the patient's upper arms and forcefully shoved the patient backwards.
- The patient turned her head towards Staff K and spit in her face.
- Staff K shoved the patient forcefully backwards and appeared to strike the right lower side of the patient's face, jaw and neck with her open hand.
- Staff K and Staff L then forcefully shoved the patient backwards, and the patient appeared to fall backwards and out of view of the video.
- When the patient came back into view, and attempted to stand up, Staff L and Staff K took hold of the patient's arms, and the patient lunged forward.
- Staff L then grabbed the back of the patient's gown, and forcefully pulled the patient backwards.
- Staff K took the patient's arm and raised it above the patient's head, then forcefully shoved the patient's right arm backward behind the patient, and continued to forcefully shove the patient backwards. Staff L also appeared to forcefully shove the patient backwards until the patient fell and Staff K fell down with the patient.
- Staff K came back into view, closed the door with the patient, Staff K, Staff L and the roommate in the room (the door remained closed with staff inside for approximately two minutes).

During an interview on 03/03/20 at 10:45 AM, Staff K, RN, stated that:
- It was not an approved Crisis Prevention Institute (CPI, a type of training whereby staff use physical holds which restrict a person's movement) technique to place an open hand on a patient's face, to forcefully "shove" a patient's arm backwards behind them or to forcefully shove a patient backwards.
- Her actions with the patient appeared "rough," she was "surprised" and "shocked" at her actions towards Patient #4, and she could have harmed the patient by forcefully pushing the patient's arm backwards.
- Acknowledged that hitting or slapping a patient on the face was abuse.

During an interview on 03/03/20 at 11:15 AM, Staff L, RN, stated that:
- Some actions by her and Staff K were a little "strong" when interacting with the patient.
- She was unsure which staffs' hand it was that struck the patient.
- Striking a patient and pushing a patient's arm backwards were not approved CPI techniques.

During an interview on 03/03/20 at 10:10 AM, Staff J, RN, Acute Psychiatric 3rd Floor Unit Manager, stated that:
- She was involved in the investigation of the alleged staff to patient abuse that involved Staff K, RN, Staff L, RN, and Patient #4.
- She did not interview Patient #8 (Patient #4's roommate) who reported that nursing staff had choked and spit on Patient #4.
- She was unable to interview Patient #4 due to the patient's refusal.
- Video review showed that staff did not use approved CPI techniques when they placed their open hand towards the patient's face and pushed the patient backwards.
- She did not believe that either Staff K or Staff L abused Patient #4.
- Staff K's and Staff L's actions towards Patient #4 were "rough."
- After she and Staff M, CNO, had completed their investigation, they determined the allegations of patient abuse against Staff K and Staff L were unsubstantiated (she did not indicate if Staff P, Risk Manager was part of the investigation, as per hospital policy).
- She did not involve Staff H, CPI Instructor/Security or Staff I, Director of Security in the investigation.

During an interview on 03/03/20 at 12:05 PM, Staff M, CNO, stated that:
- Based on Patient #4's and Patient #8's (roommate) manipulative behaviors she believed the allegations of staff abuse towards Patient #4 were not confirmed.
- She reviewed the video, and had reviewed it with various staff, and that all staff she reviewed the video with agreed that neither Staff K nor Staff L had abused the patient.
- Concerns she identified included that staff almost immediately had hands on the patient, and the door to the patient's room was closed by Staff K (there was no mention of abuse).
- She had not included Staff H, CPI Instructor/Security, or Staff I, Director of Security, in the investigation (she did not indicate if Staff P, Risk Manager, was part of the investigation).

During an interview on 03/03/20 at 2:05 PM, Staff N, Quality Risk Specialist, stated that she had viewed the surveillance video with Staff J, Manager of Acute Psychiatric 3rd Floor Unit, and Staff M, CNO, (she did not indicate if Staff P, Risk Manager, was part of the investigation) and that:
- She observed a nurse's open hand come into contact with the patient's lower face, jaw and neck.
- She had concerns with the amount of force staff had used to push the patient's arm backwards.
- She had concerns that staff were more aggressive than necessary.
- Staff K and Staff L did not use approved CPI techniques.
- Hitting, and shoving were examples of patient abuse.

During an interview on 03/04/20 at 8:30 AM, Staff P, Risk Manager, stated that:
- Her responsibilities for abuse investigations included review of video recordings, obtaining written statements and documentation of findings.
- She talked to Staff M, CNO, about the abuse report she had received, when Staff M informed her that Staff J, RN, Acute Psychiatric 3rd Floor Manager, was investigating the incident.
- After she had reviewed the surveillance video recording she requested for Staff H, CPI Instructor/Security, to view the video to determine whether approved CPI techniques were used with Patient #4.
- Staff K, RN, was required by the previous CNO to complete a refresher course in CPI, due to the use of inappropriate techniques when dealing with patients.
- She requested Staff I, Director of Security, to review the surveillance video recording to confirm if Staff K and Staff L had abused Patient #4.
- When she reported her concerns of patient abuse to Staff M, RN, CNO, Staff M informed her that the investigation was completed and closed.

The hospital failed to follow policy when they failed to include Staff P, Risk Manager, who was responsible for investigating abuse of an inpatient.

During a telephone interview on 03/03/20 at 9:00 AM, Staff H, CPI Instructor/Security stated that:
- He had viewed the video of the incident between Staff K, Staff L, and Patient #4, and had concerns with Staff K's interactions with the patient.
- Staff K did not use approved CPI techniques when she used an opened hand and struck the patient's face, jaw and neck or when she grabbed the patient's right arm and threw the patient onto the mattress.
- Hitting/striking/slapping or being rough with a patient was considered abuse.
- Staff K had a history of being rough with patients and was previously required to receive additional CPI training.
- He was concerned for patients' safety when Staff K cared for them.
- He voiced his concerns with what he observed on the video to his supervisor, Staff I, Director of Security.

During an interview on 03/03/20 at 9:25 AM, Staff I, Director of Security, stated that:
- He had viewed the video of the incident between Patient #4, Staff K and Staff L, because of a request by Staff H, CPI Instructor/Security, who had concerns with the staff to patient interaction.
- It appeared that one of the nurse's hands hit the patient's face as the patient and staff were struggling against each other.
- One nurse grabbed the patient's arm and pushed it backwards.
- Staff K and Staff L did not use approved CPI techniques.
- What he observed was staff to patient abuse.
- He had reported previous concerns he had with Staff K, RN.
- It was a concern that security was not called to investigate the incident, and that he should be involved in any investigation of alleged abuse.

The hospital failed to adequately investigate allegations of staff abuse toward Patient #4, when they failed to recognize Staff K's and Staff L's actions met the criteria for patient abuse. The hospital failed to interview Patient #4's roommate, who was present in the room during the altercation, failed to include Staff H, CPI Instructor/Security and Staff I, Director of Security, to ensure that the techniques used on the patient were approved CPI techniques, and failed to include and consider voiced concerns of abuse by Staff P, Risk Manager. These failures resulted in an incomplete investigation which lead to unsubstantiated allegations of abuse, and placed all patients at risk for their safety and health.