HospitalInspections.org

This CONDITION is not met as evidenced by :
Based on policy review, medical record review, video footage review and interview, the hospital failed to ensure patients' rights were protected to receive care in a safe setting and free from physical abuse for 1 (Patient #1) of 9 sampled patients. The failure to protect patient rights and to provide care in a safe setting resulted in failure to protect Patient #1 from verbal and physical abuse by a staff member.

The findings included:

Patient #1 was admitted to the hospital on 2/28/2023 in the Emergency Department (ED) with diagnoses of Alcohol (ETOH) Intoxication and Suicidal Ideation (SI). Patient #1 was assigned to Registered Nurse (RN) #4. Patient #1 was placed in the Behavioral Health (BH) Hallway. RN #4 engaged in a verbal argument with Patient #1 which escalated into a physical altercation. Patient #1 sustained a chest wall contusion.

Refer to A-0144 and A-0145.

Based on policy review, medical record review, video footage review, review of facility documentation and interview, the hospital failed to ensure 1 (Patient #1) of 9 sampled patients received care in a safe setting. The facility failed to maintain respect and dignity for Patient #1 and to protect his emotional and physical safety.

The findings include:

Review of the facility policy "Patient Rights and Responsibilities" dated 6/2022, revealed "...treat all patients with respect and dignity...right to receive care in a safe setting..."

Patient #1 was admitted to the hospital on 2/28/2023 at 2:50 PM in the Emergency Department (ED) with diagnoses of Alcohol (ETOH) Intoxication and Suicidal Ideation (SI). Patient #1 was assigned to Registered Nurse (RN) #4. Patient #1 was awake, alert, with slurred speech, appeared intoxicated and was eventually placed in the Behavioral Health (BH) Hallway. The BH Hallway was staffed with sitters who observed and documented on the patients placed in the hallway. Security and Metro Police had been notified Patient #1 would not remain in his assigned ED room (a consultation room equipped with a sofa and no bed) and had been asked to assist in surveillance. With security staff and police outside of Patient #1's room, Patient #1 stood in his doorway and engaged in a verbal argument with RN #4. RN #4 appeared to blow into Patient #1's face on 2 occasions at close proximity. Patient #1 placed his hand over RN #4's mouth. RN #4 pushed Patient #1 into his room where they fell into the sofa and RN #4's arm landed on Patient #1's chest wall and resulted in a chest contusion.

Review of the Emergency Provider Report, from Physician #3, dated 2/28/2023 at 2:50 PM, revealed Patient #1 entered the facility with a chief complaint of Intoxicated and SI. He was initially placed in a general purpose exam room and was later moved to the BH Hallway. Review of the Emergency Patient Record, dated 2/28/2023 at 4:13 PM, showed Patient #1 had a blood ETOH level of 407 mg/dl (high).

Review of Patient #1's Emergency Provider Report, from Physician #3, dated 2/28/2023 at 3:01 PM, revealed "...Skin: no rash, warm, dry..."

An ED note dated 2/28/2023 at 7:27 PM, from RN #4, revealed "...pt [Patient #1] continues to come out of room, demanding phone and clothes, not following commands. PD [police department] had to come to assist RN, pt still demanding and making threats, pt went to grab RN, RN had to physically grab pt arm and push pt back into room onto chair. Pt is very upset, not responding to staff. MD [Medical Doctor] aware and putting in meds [medication orders]. PD and Security present during pt acting like this..."

Review of the Physician Re-Evaluation/Progress, dated 2/28/2023 at 9:05 PM, revealed "...patient appears to have a contusion on his chest. Evidently there was some sort of an altercation with a staff member..." Patient #1's differential diagnosis was Alcohol Abuse, Anxiety, Depression, Suicidal Thoughts, and Substance-induced Mood Disorder. His condition was listed as stable.

Patient #1's Discharge/Care Plan included patient instructions on Alcohol Intoxication, and Chest Bruise (Contusion). He was discharged home following a tele-psych consultation on 2/28/2023 at 10:06 PM.

Review of the video footage, dated 2/28/2023 at 7:20 PM, revealed the following:
7:20 PM (20 sec): Patient #1 walked down the BH Hallway and walked briefly into an occupied patient's room and exited. Security officer #1 exited the Security office (located in the BH Hallway) and spoke to Patient #1. Security Officer #1 guided Patient #1 back to his assigned room. Two sitters, RN #4, and RN #2 were observed at the end of the hallway.
7:20 PM (47 sec): Patient #1 and Security Officer #1 stand in Patient #1's doorway. Patient #1 appeared to voice toward RN #4. No audio was provided in the video footage. RN #4 walked down the hallway toward Patient #1. Metro Police come into view. Patient #1 entered his room. RN #4, Security Officer #1, and the Metro Police stood in his doorway. Metro Police appeared to speak to the patient. RN #4 did not appear to speak.
7:21 PM (55 sec): Patient #1 pointed his finger at RN #4. RN #4 did not appear to speak and turned around and walked down the hallway.
7:22 PM (3 sec): Patient #1 stood in his doorway with his face away from the camera. RN #4 turned around and walked back to Patient #1. Security and the police were present in the hallway.
7:22 PM (8 sec): RN #4 approached Patient #1 and in proximity (approximately 6 to 8 inches), pointed his finger at the patient while speaking to him. The RNs hands were behind his back.
7:22 PM (17 sec): RN #4 appeared to inhale breaths and blew in Patient #1's face 2 times.
7:22 PM (19 sec): Patient #1 placed his right hand over RN #4's mouth. RN #4 pushed the patient into his room. There was no video footage inside the consultation room. Security entered the room. Metro Police remained in the hallway.
7:22 PM (39 sec): RN #4 exited Patient #1's room and walked down the hallway. Security remained in the room.
7:22 PM (43 sec): RN #4 turned around, walked back to Patient #1's room, and spoke to the patient from the doorway, and walked back down the hallway. Metro Police remained at the doorway.
7:22 PM (50 sec): Security exited the room.
7:22 PM (52 sec): Patient #1 appeared at his doorway, pointed down the hallway toward RN #4 and appeared to speak. Metro Police entered the Security Office. Security Officer #1 was present in the hallway outside of Patient #1's room.
7:22 PM: (56 sec): RN #4 raised his left arm and hand. End of video.

A review of the facility documentation, Vigilanz Report (Behavior Event), dated 2/28/2023 at 7:20 PM, from RN #5, revealed staff behavior issue "inappropriate behavior." The staff inappropriate behavior "physically abusive" with the brief objective description as ''staff member pushed pt." Additional comments revealed RN #5 had observed the video footage, "...[RN #4] rushed toward a pt, got into his face. Started blowing in the pts face, then when the pt went to push [RN #4] away, [RN #4] pushed the pt into the room. Security reports he was the only individual to lay hands on pt..." The Impact of the Event "Harm" with further explanation of impact "...pt developed bruising on chest. See attached images..."

Review of facility documentation of Patient #1's chest wall, undated, revealed 2 colored photographs of a hairy, chest wall with a reddened area to the center of his chest.

During an interview on 10/24/2023 at 2:40 PM, with Nurse Manager RN #5 and the Director of ED Services, in a Conference Room, RN #5 stated 2/28/2023 was RN #4's first day in the ED following an orientation in the facility. He stated he was informed of the incident from Security. He did not witness the altercation. He notified the Director of ED Services. He stated he located RN #4 in the break room. He informed him he had watched the video. RN #4 said he defended himself from the patient. He instructed him to leave the facility and not to return until he was contacted from the facility. He stated he never returned to the facility. He stated he assessed Patient #4 and observed a bruise to his chest wall. He said the patient refused imaging and did not want to be examined. He stated he refused to take the phone number for the Patient Safety Director and refused to file a police report. The Director of ED Services confirmed RN #5 notified her of the incident. She stated she notified his contract agency and facility leadership.

During an interview on 10/24/2023 at 4:07 PM, with RN #3, he stated he heard RN #4 and Patient #1 arguing in the hallway, "...he [RN #4] was yelling at the patient...he walked away from the patient...the patient was taunting him...[RN #4] turned around and pointed his finger at him...I saw the patient spit at him...I turned around to get the charge nurse [RN #5]..." He stated RN #5 asked to talk to RN #4. He said RN #4 had left following the incident. He stated he had not seen RN #4 again.

During a telephone interview, on 10/25/2023 at 1:00 PM, ED Physician #3 stated he was Patient #1's physician on 2/28/2023. He stated he documented a contusion "...it wasn't significant enough to order an X-Ray of the chest..." He said he did not recall Patient #1 saying anything about RN #4.

During a telephone interview on 10/25/2023 at 2:55 PM, Security Officer #1 stated he was in the BH Hallway with Patient #1 because he had questions about his psychiatric hold and wanted to hear it from an officer. He stated his nurse [RN #4] joined into the conversation about why the patient was unable to leave the facility. He said Patient #1 wanted to leave the facility. Security Officer #1 stated the patient and RN #4 "...started to get into it...the nurse started to walk away...the patient said 'I bet you won't say it to my face'...that's when the nurse turned around and got in the patient's face. I believe he [RN #4] said why the patient was here...I think the patient thought it was a rude comment...The patient stated your breathe stinks. The nurse started blowing in his face. The patient put his hand up to block the air...and touched the nurses face. That's when the nurse touched the patient...the nurse grabbed the patient...they fell onto the couch the nurse went with him onto the couch landing with the nurse's arm on the patient's chest..." He stated the nurse's arm was around the sternum area of the chest for an estimated length of time of less than 30 seconds. He said it all happened very quickly after the patient put his hand over the nurse's mouth. He helped RN #4 up and the nurse walked out of the room. He stayed with the patient for a minute and then informed his supervisor who instructed him to inform the ED Charge Nurse. He was unable to recall if the nurse and the patient said anything to each other inside the Consultation Room.

During an interview on 10/30/2023 at 9:38 AM, the Patient Safety Director stated the facility completed an investigation of the allegation. The facility filed a report to the Board of Nursing, contacted his contract agency, and notified them the facility and their surrounding sister facilities would not be using RN #4's nursing services. She stated his termination with the facility was effective 2/28/2023.

During a telephone interview with RN #4 on 10/30/2023 at 1:25 PM, RN #4 stated he had been in-serviced on abuse and patient rights at the facility. He stated he had a conflict with a patient in the ED "...yeah...one drunk guy put in front of me...all day long I had to redirect him...to stay in his room...he cussed me for hours...I heard a ruckus in the hallway...1 security officer and 1 police officer...I told them to do their jobs and to keep him in his room...the patient said something to me. I told him he was on a psych hold...he couldn't leave. Security just stood there. He [Patient #1] said my breath stunk. I breathed in his face to get him out of my bubble. He put his hand on my face..." He stated he put both hands on his arms to get him back into his room. He said he sat him down on the sofa. Patient #1 reached for him, and he pushed him back into the sofa. He said he resigned from the facility on 2/28/2023. He stated he had a hearing with the Board of Nursing. An agreement had been made but had not been signed. He refused to disclose where he was presently working. He stated he resigned from his contract agency.

During an interview on 11/2/2023 at 9:36 AM, the Director of ED Services stated she was notified of the incident by RN #5. She stated the facility informed the contract agency RN #4 was not allowed to return to the facility. She confirmed the facility substantiated the incident.

During a telephone interview on 11/2/2023 at 10:00 AM, the Chief Nursing Officer (CNO) confirmed she was notified of the incident. She stated the facility substantiated the allegation "...it was an accurate complaint...". She stated RN #4 escalated the situation "...the nurse drove the increased behavior...". She confirmed she submitted a report of the facility investigation to the Board of Nursing. She confirmed it was her expectation for facility staff to protect patient rights and to provide a safe environment "...yes...dignity, all those things are expectations in that situation..."

Based on facility policy review, medical record review, video footage review, review of facility documentation and interviews, the facility failed to ensure patient rights were protected for 1 (Patient #1) of 9 patients sampled by failing to protect Patient #1 from verbal and physical abuse.

The findings included:

Review of the facility policy "Alleged or Suspected Abuse (Child and/or Adult)" dated 9/2023, revealed "...any staff member having knowledge or suspicion of...adult/domestic abuse/neglect...shall report such knowledge or suspicion...if abuse or neglect is known or suspected to be inflicted on a patient by [hospital facility] staff member during the patient's hospitalization...remove the [hospital facility] staff member...report immediately...notify...Directors and/or Departments..."

Patient #1 was admitted to the hospital on 2/28/2023 at 2:50 PM in the Emergency Department (ED) with diagnoses of Alcohol (ETOH) Intoxication and Suicidal Ideation (SI). Patient #1 was assigned to Registered Nurse (RN) #4. Patient #1 was awake, alert, with slurred speech and appeared intoxicated. Patient #1 was eventually placed in the Behavioral Health (BH) Hallway. The BH Hallway was staffed with sitters who observed and documented on the patients placed in the hallway. Security and Metro Police had been notified Patient #1 did not remain in his assigned ED room (a consultation room equipped with a sofa and no bed) and had been asked to assist in surveillance. With Security and police outside of Patient #1's room, Patient #1 stood in his doorway and engaged in a verbal altercation with RN #4. RN #4 appeared to blow into Patient #1's face on 2 occasions at close proximity. Patient #1 placed his hand over RN #4's mouth. RN #4 pushed Patient #1 into his room where they fell into the sofa and RN #4's arm landed on Patient #1's chest wall and resulted in a chest contusion.

Review of the ED medical record, dated 2/28/2023 at 2:50 PM, revealed Patient #1 entered the facility with a chief complaint of Intoxicated and SI. He was initially placed in a general purpose exam room, but refused to remain in his room, and was moved to the BH Hallway.

Review of Patient #1's Emergency Provider Report, dated 2/28/2023 at 3:01 PM, from Physician #3, revealed "...Skin: no rash, warm, dry..."

Review of the Emergency Patient Record dated 2/28/2023 at 4:13 PM, showed Patient #1 had a blood ETOH level of 407 mg/dl (high).

A nursing note dated 2/28/2023 at 7:27 PM, from RN #4, revealed "...pt [patient] continues to come out of room, demanding phone and clothes, not following commands. PD [police department] had to come to assist RN, pt still demanding and making threats, pt went to grab RN, RN had to physically grab pt arm and push pt back into room onto chair. Pt is very upset, not responding to staff. MD [Medical Doctor] aware and putting in meds [medication orders]. PD and Security present during pt acting like this..." A note dated 2/28/2023 at 9:31 PM by RN #2 revealed "...Pt is very agitated...tried to leave his room...yelling and cussing at the staff...waiting for the telehealth psych...sitters in place..."

Further review of the Re-Evaluation/Progress, dated 2/28/2023 at 9:05 PM, revealed "...patient appears to have a contusion on his chest. Evidently there was some sort of an altercation with a staff member...". Patient #1's differential diagnosis was Alcohol Abuse, Anxiety, Depression, Suicidal Thoughts, and Substance-induced Mood Disorder. His condition was listed as stable.

Review of Patient #1's Discharge/Care Plan included patient instructions on Alcohol Intoxication, and Chest Bruise (Contusion).

Review of the discharge record showed Patient #1 was discharged home following a tele-psych consultation on 2/28/2023 at 10:06 PM.

A review of the facility documentation, Vigilanz Report (Behavior Event), dated 2/28/2023 at 7:20 PM, from RN #1, revealed staff behavior issue was listed as "inappropriate behavior". The staff inappropriate behavior was listed as "physically abusive" with the brief objective description as ''staff member pushed pt". Additional comments revealed RN #1 had observed the video footage "...[RN #4] rushed toward a pt, got into his face. Started blowing in the pts face, then when the pt went to push [RN #4] away, [RN #4] pushed the pt into the room. Security reports he was the only individual to lay hands on pt..." The Impact of the Event was listed as "Harm" with further explanation of impact "...pt developed bruising on chest. See attached images..."

Observation of facility documentation of Patient #1's chest wall, undated, revealed 2 colored photographs of a hairy, chest wall with a reddened area to the center of his chest.

Review of a witness statement, not dated, from Security Officer #1, revealed "...approximately 1915 (7:15 PM) patient outside hallway...[RN #4] arrived...blew into his face...[Patient #1] tried to cover RN's face...Metro Police followed into room...nurse on top of patient..."

Review of the video footage, dated 2/28/2023 at 7:20 PM, revealed the following:
7:20 PM (20 sec): Patient #1 walked down the BH Hallway and walked briefly into another occupied patient's room and exited. Security officer #1 exited the Security office (located in the BH Hallway) and spoke to Patient #1 after observation of Patient #1 walking down the BH Hallway and entering another patient's room. Security Officer #1 guides Patient #1 back to his assigned room. Two sitters were observed at the end of the hallway, along with RN #4 and RN #2.
7:20 PM (47 sec): Patient #1 and Security Officer #1 stand in Patient #1's doorway. Patient #1 appeared to voice toward RN #4. No audio was provided in the video footage. RN #4 walked down the hallway toward Patient #1. Metro Police come into view. Patient #1 entered his room. RN #4, Security Officer #1, and the Metro Police stood in his doorway. Metro Police appeared to speak to the patient. RN #4 did not appear to speak.
7:21 PM (55 sec): Patient #1 pointed his finger at RN #4. RN #4 did not appear to speak and turned around and walked down the hallway.
7:22 PM (3 sec): Patient #1 stood in his doorway with his face away from the camera. RN #4 turned around and walked back to Patient #1. Security and the police were present in the hallway.
7:22 PM (8 sec): RN #4 approached Patient #1 and in close proximity (approximately 6 to 8 inches), pointed his finger briefly at the patient while speaking to him. Both of the RNs hands were behind his back.
7:22 PM (17 sec): RN #4 appeared to take breaths in and blew in Patient #1's face 2 times.
7:22 PM (19 sec): Patient #1 placed his right hand over RN #4's mouth. RN #4 pushed the patient into his room. There was no video footage inside the consultation room. Security entered the room. Metro Police remained in the hallway.
7:22 PM (39 sec): RN #4 exited Patient #1's room and walked down the hallway. Security remained in the room.
7:22 PM (43 sec): RN #4 turned around, walked back to Patient #1's room, and spoke to the patient, and walked back down the hallway. Metro Police were at the doorway.
7:22 PM (50 sec): Security exited the room.
7:22 PM (52 sec): Patient #1 appeared at his doorway, pointed down the hallway toward RN #4 and appeared to speak. Metro Police had entered the Security Office. Security Officer #1 was present in the hallway outside of Patient #1's room. RN #4 appeared at the end of the hallway.
7:22 PM: (56 sec): RN #4 raised his left arm and hand. End of video.

During an interview Nurse Manager RN #1 and the Director of ED Services, on 10/24/2023 at 2:40 PM, RN #1 stated 2/28/2023 was RN #4's first day in the ED following a 1-day orientation in the facility. He stated he was informed of the altercation by Security. He did not witness the altercation. He notified the Director of ED Services. He stated he located RN #4 in the break room. He informed him he had watched the video. RN #4 said he defended himself from the patient. He said he instructed him to leave the facility and to not return until he was contacted from the facility. He stated he never returned to the facility. He stated he assessed Patient #4 and observed a bruise to his chest wall. He said the patient refused imaging and did not want to be examined. He stated he refused to take the hospitals phone number for the Patient Safety Director and refused to file a police report. The Director of ED Services confirmed RN #1 notified her of the allegation. She stated she notified his contract agency and facility leadership.

During an interview on 10/24/2023 at 4:07 PM, RN #3 stated he heard RN #4 and Patient #1 arguing in the hallway "...he [RN #4] was yelling at the patient...he walked away from the patient...the patient was taunting him...[RN #4] turned around and pointed his finger at him...I heard him arguing with the patient and the patient mouthing off...I saw the patient spit at him...I turned around to get the charge nurse [RN #1]..." He stated RN #1 asked to talk to RN #4. He said RN #4 had left following the incident. He stated he had not seen RN #4 again.

During a telephone interview on 10/25/2023 at 1:00 PM, ED Physician #3 stated he was Patient #1's physician on 2/28/2023. He stated he documented a contusion "...it wasn't significant enough to order an X-Ray of the chest..." He said he did not recall Patient #1 saying anything about RN #4.

During a telephone interview on 10/25/2023 at 2:55 PM, Security Officer #1 stated he was in the BH Hallway with Patient #1 because he had questions about his psychiatric hold and wanted to hear it from an officer. He stated his nurse [RN #4] joined into the conversation about why he was unable to leave the facility. He said Patient #1 wanted to leave the facility. Security Officer #1 stated the patient and RN "...started to get into it...the nurse started to walk away...the patient said 'I bet you won't say it to my face'...that's when the nurse turned around and got in the patient's face. I believe he [RN #4] said why the patient was here...I think the patient thought it was a rude comment...The patient stated your breathe stinks. The nurse started blowing in his face. The patient put his hand up to block the air...and touched the nurses face. That's when the nurse touched the patient...the nurse grabbed the patient...they fell onto the couch with the nurse went with him onto the couch landing with the nurse's arm on the patient's chest..." He stated the nurse's arm was around the sternum area of the chest for an estimated length of time of less than 30 seconds. He said it all happened very quickly after the patient put his hand over the nurse's mouth. He helped RN #4 up who walked out of the room. He stayed with the patient for a minute and then informed his supervisor who instructed him to inform the ED Charge Nurse.

During an interview on 10/30/2023 at 9:38 AM, the Patient Safety Director, stated an investigation was completed on the allegation. The facility filed a report to the Board of Nursing, contacted his contract agency, and notified them the facility and their surrounding hospitals would not be using RN #4's nursing services. She stated his termination with the facility was effective 2/28/2023. She stated all employees were trained annually on abuse and upon hire to the facility.

During a telephone interview on 10/30/2023 at 1:25 PM, with RN #4 he stated he had been in-serviced on abuse at the contract agency and the facility. He stated he had a conflict with a patient in the ED "...yeah...1 drunk guy put in front of me...all day long I had to redirect him...to stay in his room...he cussed me for hours...I heard a ruckus in the hallway...1 security officer and 1 police officer...I told them to do their jobs and to keep him in his room...the patient said something to me. I told him he was on a psych hold...he couldn't leave. Security just stood there. He said my breath stunk. I breathed in his face to get him out of my bubble. He put his hand on my face..." He stated he put both hands on his arms to get him back into his room. He said he sat him down on the sofa. Patient #1 reached for him, and he pushed him back into the sofa. He said he quit the facility on 2/28/2023. He stated he had a hearing with the Board of Nursing. An agreement had been made but had not been signed. He refused to disclose where he was presently working. He stated he resigned from his contract agency.

During an interview the Director of ED Services, on 11/2/2023 at 9:36 AM, stated she was notified of the incident by RN #1. She stated the facility informed the contract agency RN #4 was not allowed to return to the facility. She confirmed the facility substantiated the incident and the allegation of abuse.

During a telephone interview the Chief Nursing Officer (CNO), on 11/2/2023 at 10:00 AM, confirmed she was notified of the incident. She stated the facility substantiated the allegation "...it was an accurate complaint..." She stated RN #4 escalated the situation "...the nurse drove the increased behavior..." She confirmed she submitted a report of the facility investigation to the Board of Nursing. She confirmed it was her expectation for facility staff to protect patient rights and to provide a safe environment "...yes...dignity, all those things are expectations in that situation..."