HospitalInspections.org

Based on observation, interview and record review the facility failed to implement their policy for investigating allegations of abuse for 1 (#1) of 4 patients reviewed for allegations of abuse, resulting in the potential for less than optimal outcomes for all patients served by the facility. Findings include:

Patient #1 was observed on 4/15/2021 at 1420 requesting to speak with the surveyor. The patient was offered privacy and the interview was conducted in her room. The patient said she had been assaulted by one of her peers (patient #2). Patient #1 stated, "(#2) threw her headphones at me and look at this bruise that was left." She said, I told them and nothing was done about it. At that time, the patient lifted her top and a fist sized circular yellowish-bluish discoloration was noted to the patient's right lower flank.

A review of the medical record for patient #1 was conducted on 4/15/2021 at 1130 with Staff C and revealed the following:
Patient #1 was a 37 year-old-female admitted to the facility on 9/17/2020.

Review of "Behavioral/Medical Event (BME) Progress" note dated 4/12/2021 at "1-2:15" PM documented: Patient (#1) requesting to speak to 2 treatment team members who are not present today, Registered Nurse (RN) inquires if there is something the present RN may assist with. Patient reports "I have a bruise from when she (another female peer) threw her headphones at me" and referenced peer throwing crayons at her and reports that peer threw headphones in addition. Bruise is tennis ball size around and circular in nature. Bruise is purplish in color. After RN assessed, patient denies any treatment is needed/cold compress. Rather patient is reporting to RN that she is "calling child protective services to report her because she would not come off her level today." After listening, patient informed her bruise would be documented, as would the reported cause of the bruise. Patient appeared and sounded satisfied with this. At 2:15 PM, patient was on the phone reporting the same information as noted. Peer (#2) could hear patient speaking and came to doorway, yelling "stop talking about me."

Review of an "Incident/Accident Report (I&A) dated 4/8/2021 at 0348 PM, revealed the following:
Type of Incident: Patient (#1) to Patient (#2) Assault on 4/8/2021 at 0243 PM.
Explain what happened: During programming, patient and peer were both wanting to use some of the shared supplies. Patient offered to share and was in the process of moving closer to peer for sharing purposes. Peer verbalized patient was too close. Patient got up abruptly and sat down in a different spot, calling peer a (profane name). Shortly after, patient apologized and peer reported "I don't want to hear that." Patient (#2) then threw the markers at the peer and motioned in effort to attack peer. Manual hold initiated back to a seated position.
Action taken: Assured Patient of Safety, RN Assessed patient for injury.

On 4/15/2021 at 1500 Staff C was asked if there were any other I&A's for patient #1 in regards to the bruise that was identified by the RN on the BME progress note dated 4/12/2021 at 0352 PM. At that time, Staff C replied, no there is not. Staff C said an I&A should have been entered since the RN documented a bruise on the patient.

Review of the facility's "Reporting Unusual Incidents-Incident Report (IR)" policy, dated revised on 1/8/2020 and implemented on 1/13/2020 revealed:
Definitions:
"Unusual Incident ...2. Any accident or injury of a patient and/or any accident or incident which may have caused injury, including incidents in which the patient requests and allows application of Manual Restraints ...c. Patient physical aggression (aggressor and victim).
Procedures:
A. Whenever an Unusual Incident occurs: 1. All employees, contracted or healthcare employees and students will: a. Report any unusual incident to a Registered Nurse (RN) immediately.
b. Complete an IR on each patient who is directly involved in an unusual incident. (If a patient is a witness (as a bystander) to the incident that does not constitute direct involvement in the incident.
i. Open the incident in the electronic medical record and complete the necessary forms, as directed by the
RN Manager.
ii. For non-clinical staff that do not have access to the EMR, the paper IR form will be completed.
c. Forward to the Unit RN the completed IR forms in the EMR or a pre-numbered paper IR form ...5. Hospital Director or Designee will: Notify the Recipient Rights Advisor of cases of serious injury, death, suicide attempt, suspected client abuse or neglect ...".
However, that was not done.

On 4/19/2021 at 1345 an interview was conducted with the Hospital Director Staff A regarding the injury (bruise) that the patient of concern #1 had expressed that "nothing has been done."
At that time, Staff A said, an I&A should have been implemented. She (Staff A) said, "we failed to follow our policy for "Reporting Unusual Incidents."