Bringing transparency to federal inspections
Tag No.: A0145
Based on record review and interview the hospital failed to ensure patients were free from harassment for 1 of 10 patients reviewed, Patient #1. Findings include:
Medical record review revealed that Patient #1 was admitted to the hospital 11/17/2011 with diagnoses that included suicidal ideation and mood disorder. Patient #1 required 1 to 1 staffing during her admission.
Psychology/neuropsychology progress notes written by Physician B/Licensed Psychologist dated 12/7/2011 were reviewed and revealed that on 12/6/2011 and 12/7/2011 Patient #1's 1 to 1 staff was Employee D/Human Services technician/HST. Patient #1 told her physician that Employee D made remarks about Patient #1's family being unhealthy, and that she should not be sent home to her family because she keeps being rehospitalized. The notes further indicate that Patient #1 thought this interaction was abusive and that she would rather be in jail than to continue to be abused. The notes indicated that Patient #1 stated that this interaction contributed to her behavior on 12/7/2011 including damaging her room, and requiring restraint.
An interview with Physician B on 1/24/2012 at 3:00 p.m. revealed that Patient #1 told her about the interactions with Employee D on 12/7/2011. Physician B confirmed that Patient #1 told her that Employee D stated that Patient #1 should not go home because it was not good for her. Physician B stated that she understood from the patient that Patient #1 requested Employee D to stop, but Employee D did not do so. Physician B stated that Patient #1 stated she felt threatened by the interaction. Physician B stated that an HST, such as Employee D, does not have the skills for therapy and should not be interacting with patients on that level. Physician B further stated that it is especially troubling when a patient is on a 1 to 1 staffing and does not have the option to walk away.
Employee C/RN/Supervisor was interviewed on 1/19/2012 at 2:00 p.m. and stated that she investigated that concern that Patient #1 voiced regarding Employee D. Employee C stated that Patient #1 requested to not have Employee D as her 1 to 1 staff on 12/7/2011 and that Employee D was then removed from that duty. Employee C stated that Employee D denied that she made any comments about Patient #1's home or family. Employee C also stated that other patients have complained about Employee D being inappropriate. Employee C stated that she has not yet finished her investigation, but that she has limited Employee D's duties and she is no longer providing 1 to 1 care to patients.
Employee D's personnel file was reviewed and revealed that she had a previous history of nontherapeutic interaction with patients and disciplinary actions including:
A suspension in 2010 for speaking about personal information about herself and coworkers in front of patients and being confrontational with her co-workers.
A suspension in 2009 for inappropriate workplace behavior in front of patients.
A suspension in 2007 for inappropriate/unprofessional behavior/boundaries towards a patient.