HospitalInspections.org

Based on review of the facility's policies and procedures, medical records (#s 1-10), staffing and training records, digital video recording, employee files (# ' s 1, 2, 3, 4, 6, 8 and 9), and staff and patient interviews, it was determined that the facility failed to protect a patient (#1) from physical abuse, and that staff failed to accurately and timely report the abuse at the time of the incident.

Findings were:

Review of policy entitled " "Personnel Actions in Cases of Abuse, Neglect and/or Exploitation of Individuals Serviced by DBHDD (Department of Behavioral Health and Developmental Disabilities), 22-1603, adopted 07/01/2009, last revised 08/01/2013 revealed that DBHDD has the legal and ethical responsibility to protect all individuals who receive services by or funded by DBHDD. DBHDD also recognizes its responsibility to employees for equitable treatment and for a reasonably safe and healthy place to work. Any form of physical abuse, sexual abuse, exploitation, neglect, financial exploitation or psychological or verbal abuse of individuals, as well as failure to report critical incidents, is misconduct and is prohibited.

In accordance with State law, separation from employment and a referral for criminal prosecution to local law enforcement officials is mandatory in cases where any employee assaults any individual served in any DBHDD facility or institution, or who shall knowingly use against any such individual any other or greater force than the occasion may require. A referral to law enforcement may be made in other cases, as deemed appropriate. Other violation of policies, procedures, standards, rules or regulations will result in appropriate corrective or disciplinary action, up to and including separation from employment.

DBHDD policies regarding the reporting of incidents are strictly adhered to in reporting allegations of any type of abuse, neglect or exploitation. Reports are promptly made in accordance with the respective incident management policy. In instances of allegations of physical abuse, sexual abuse, or exploitation, the employee must be suspended with pay or administratively reassigned pending completion of the investigation. An employee who fails to properly notify or report suspected cases of any type of abuse, neglect, or exploitation is subject to disciplinary action up to, and including separation from employment, and/or criminal prosecution when warranted. All investigative reports of suspected individual abuse, neglect or exploitation are sent to the appointing authority (Regional Hospital Administrator, Regional Coordinator or applicable Division or Office Director) or their designee for appropriate personnel action. These reports include a statement from the Office of Incident Management and Investigations (OIMI) determining whether there was a use of excessive force and a recommendation for Human Resources action when allegations are substantiated. Personnel actions are coordinated with the DBHDD Office of Human Resources.

Review of the video of the incident on 09/01/16 at 11:45 a.m. revealed that employee #4 struck patient #1 in the face, grabbed his/her hair, dragged him/her a few feet, pulled the patient down to the floor and sat on the patient in a prone position slightly on his/her/his side.

Review of the incident report revealed that the incident was not reported as it occurred in the video. The incident report stated that patient #1 assaulted employee #4 by throwing his/her juice in employee #4's face and striking employee #4.

During an interview on 08/31/16 at 10:00 a.m. in the administrative conference room, the manager of the General Mental Health Unit (employee #6) stated that he/she had been an RN since 2004 and had been employed at this facility since 04/2016. The nurse manager stated that this incident happened on the evening shift and that he/she learned about it the next day.
Employee #6 stated that after he/she was informed of the video recording and viewed the videotape of the incident, employee #4 was immediately re-assigned to a non-patient area, and that employee #4 resigned shortly thereafter. Employee #6 revealed that the video showed the patients were standing in line to get their medications and their snacks. Patient #1 got upset and threw juice on employee #4. Employee #4 grabbed patient #1 by the hair and both went down to the floor together. Employee #4 ended up sitting on top of patient #1. The video showed that patient #2 and other staff closed in to help. An incident report was completed by the charge nurse, but the incident report was not accurate, and failed to report the altercation between employee #4 and patient #1. Employee #6 stated that he/she did not realize that patient abuse had occurred until he/she viewed the video tape.
Employee #6 stated that he/she had not talked to the HSTs (employee #s 1, 2, and 4), who were also seen in the video, as he/she was waiting on a final report from the Office of Incident Management Investigations (OIMI) investigator. Employee #6 stated that he/she had talked to staff about safety and patient abuse at the staff meeting prior to this incident. He/she stated that his/her job was to notify the nursing office, call security and re-assign the staff member which he/she did.
Employee #6 stated that all employees receive two (2) days of Safety Care training during their initial orientation and that all employees are re-educated on Safety Care yearly. He/she also meets with the staff every month and goes over safety issues.
Employee #6 stated that staffing on the day shift consisted of 4 RNs, 2-3 LPNs, a charge nurse and ten (10) HSTs. Evening shift has 3 RNs, 2 LPNs and 7-8 HSTs. On the night shift there were 2-3 RNs, 1-2 LPNs, and 6 HSTs. He/she stated that the unit was capable of thirty-five (35) patients but that their average census was twenty-eight (28) to twenty-nine (29) patients.
During an interview on 8/30/2016 at 3:00 p.m. in an administration conference room, the Unit Program Director, a psychologist (#5) stated that a member of the Recovery Facilitation Team (coordinates treatment plan meetings and reviews any incident reports) requested that an incident involving patient #1 be reviewed. Employee #5 reviewed a video recorded at the time of the incident. Employee #5 reveals that patient #1 threw juice in the face of employee #4. Employee #4 then grabbed patient #1 by the hair and threw him/her to ground. Employee #4 then sat on top of patient #1. The video that employee #5 viewed was such that other employees could not be seen. The recorded video does not have audio capabilities. Employee #5 immediately reported the incident to the Clinical Director (now deceased). Employee #5 stated that the Clinical Director reported the incident to Risk Management and Nursing Administration. Employee #5 reveals that employee #4 was immediately reassigned to a non-clinical role but was not certain to the timeframe.

During an interview on 08/31/16 at 3:30 p.m. in the administrative conference room, employee #1, an HST stated that he/she had been employed at the facility since 06/2016. Employee #1 stated that on the day of the incident he/she arrived on the Unit around 3:30 p.m. and that patient #1 was in a bad mood. At the time of the incident he/she was in an area where the nurses were giving the patient their medications and he/she was providing the patients with their snacks. Employee #1 stated that employee #4 reminded her who the diabetics were and that he/she then offered patient #1 a fruit snack, but the patient wanted a chocolate snack. Employee #1 stated that employee #4 told patient #1 that he/she could not have a chocolate snack. Patient #1 started calling employee #4 names, racial slurs, and threatening him/her. Patient #1 told employee #4 that he/she was going to throw juice in his/her face. The patient then threw grape juice into employee #4's face and the two went at each other and both ended up on the floor with employee #4 on top of the patient on the floor holding the patient down. Another HST was holding the patient's hands. Employee #1 stated that he/she was very blurry about what happened, but stated that he/she did not see any improper behavior. Employee #1 stated that when she looked up the two were on the floor. Employee #1 stated that the Safety Care orientation training was adequate, but that he/she would appreciate training every six (6) months instead of every year. He/she also stated that there was not enough staff especially on the weekend when they worked twelve (12) hours and had to double back early that next week. He/she stated that he/she was unable to get more than three (3) hours sleep with that turn-around.
During an interview on 08/31/16 at 4:00 p.m. in the conference room, employee #3 stated that he/she was employed as an HST since 05/2016. Employee #3 stated that on the day in question, he/she was doing a 2:1 and was in the room with the patient that he/she was observing. He/she stated that he/she heard a noise and when he/she looked out of the room, he/she saw employee #4 and patient #1 on the floor. Employee #3 stated that patient #1 had an attitude. Employee #3 stated that he/she grabbed patient #2 to keep him/her out of the situation. Employee #3 stated that he/she felt that the Safety Care training was adequate to address the frequent altercations on the Unit.
During an interview on 08/31/16 at 4:25 p.m. in the administrative conference room, employee #2 stated that he/she had been employed as an HST since 03/01/16. Employee #2 stated that he/she heard a commotion as he/she was leaving the area. He/she stated that employee #4 was on the ground with patient #1, and the patient was fighting back, was upset, was cursing and name calling. Employee #2 stated that employee #4 was on top of the patient who was on his/her side. Employee #2 stated that patient #1 was upset before the incident happened. Employee #2 stated that he/she felt that the training during orientation was adequate, but felt that staffing was not adequate on the evening shift.
On 9/1/2016 at 09:30 a.m., an interview with patient #2 was conducted in a private office in the lobby of the patient unit. Patient #2 stated that he/she recalled the incident in question. Patient #2 revealed that he/she was coming out of the restroom and saw patient #1 on the floor with employee #4 on top of him/her. Patient #1 was kicking and yelling. Patient #2 revealed that employee #4 'body slammed' patient #1. Patient #2 revealed that employee #4 had been aggressive with him/her (patient #2) and other patients in the past. Patient #2 revealed that patient #1 frequently used foul language and threatened staff and other patients. Patient #2 revealed that as a result of this incident, patient #1 hurt his/her finger.