HospitalInspections.org

Based on record review and interview the facility failed to immediately report an allegation of caregiver abuse/misconduct in 1 of 1 caregiver misconduct allegations reviewed (Patient #1) in a total sample of 1 caregiver misconduct allegations reviewed.

Findings Include:

A review of the facility's policy titled, "Reporting and Investigating Patient Abuse Procedure" last revised 08/2022 revealed, "... The employee who suspects abuse... must immediately contact the RN (Registered Nurse) on the unit to report the alleged abuse..."

A review of the facility's policy titled, "Crisis Prevention and Management Program" last revised 05/2024 revealed, "... Interventions Not Permitted: ... Any application of undue pressure to any part of a patient's body ... "

A review of Patient #1's medical record revealed that Patient #1 was a 59-year-old male with a history of altered mental status who was admitted to the facility on 02/25/2025 at 1:57 AM under a court order for treatment after he was found at a train station wandering around and was admitted for catatonia (a psychomotor disorder characterized by unusual movements, behaviors, and a disconnection from the environment- can also present as confusion, restlessness and agitation). Patient #1 remained a "1:1" status for his admission because he was considered a "high fall risk." Patient #1 was discharged from the facility with his guardian on 03/20/2025 at 8:29 AM.

A review of the facilty's document titled, "Employee Investigation Reports" revealed that PCT (Psychiatric Care Technician) A performed an untrained CPM (crisis-prevention-management) technique on Patient #1 on 02/28/2025 when he held Patient #1 down in their bed by their shoulders and this was witnessed by PCT G at approximately 1:00 AM. Review of the "Employee Investigation Reports" revealed that PCT G did not report the alleged abuse by PCT A to Patient #1 until approximately 3:00 AM-4:00 AM.

During an interview on 04/18/2025 at 9:35 AM with DON (Director of Nursing) I, when asked about abuse reporting, DON I stated, "I expect that it would be reported right away."

Based on record review and interview, facility staff failed to perform a nursing assessment and evaluate a patient after alleged abuse in 1 of 1 patients (Patient #1) in a total sample of 1 caregiver misconduct allegations reviewed.

Findings Include:

A review of the facility's policy titled, "Reporting and Investigating Alleged Patient Abuse Procedure" last revised 08/2022 revealed, "... [Hospital name] employees... must follow the following steps if they suspect possible occurrence of patient abuse: ... The RN (Registered Nurse) will conduct a physical assessment when applicable to assess for any injuries..."

A review of the facility's "Employee Investigation Reports" revealed that PCT A performed an untrained CPM (crisis-prevention-management) technique on Patient #1 on 02/28/2025 when he held Patient #1 down in their bed by their shoulders and this was witnessed by PCT (Psychiatric Care Technician) G at approximately 1:00 AM.

A review of Patient #1's medical record revealed: "Assessment" on 02/28/2025 at 5:30 AM by RN V (approximately 4 hours after the incident occurred): "Neurological: Level of Consciousness: Alert; Psychosocial: ... Behavior: Calm, Cooperative." Review of "Shift Summary" on 02/28/2025 at 5:30 AM by RN V revealed: "1:1 supervision continues for safety. Slept well. No behavioral issues ... Assessed and met needs, Communicated with physician, Encouraged to seek out staff assistance if needed ..." Review of Patient #1's medical record revealed there were no further physical assessments documented on Patient #1 such as a comprehensive physical assessment, pain level, or vital signs after the abuse occurred.

During an interview on 04/18/2025 at 9:36 AM with DON (Director of Nursing) I, when asked what the nursing assessment process is after suspected abuse has occurred, DON I stated, "I would expect to see more of a physical assessment from the nurse."