HospitalInspections.org

Based on review of records and interview, the facility failed to:

A) protect vulnerable behavioral health patients from physical and emotional trauma. Review of 27 patients (Patient #'s 1, 2, 4, 6, 7, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 22, 23, 24, 25, 26, 27, 28, 29, 30, 32, and 33 ) of 27 patient incident reports revealed that patients who were victims of, or witnesses to traumatic incidents, did not receive appropriate identification and interventions related to traumatic or harmful experiences that occurred during their stay in the facility.

B) aggregate, track, trend, and analyze data from violent, aggressive, and assaultive behaviors reported through the incident reporting system, TRIDEO, to improve patient safety and outcomes.

Cross Refer to Tag A0144

C) prevent vulnerable patients who were being treated in an inpatient psychiatric setting at the Behavioral Health Center (BHC) from violent, aggressive, and assaultive behaviors of other patients in review of 27 patients (Patient #'s 1, 2, 4, 6, 7, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 22, 23, 24, 25, 26, 27, 28, 29, 30, 32, and 33 ) of 27 patient incident reports.

D) investigate allegations of sexual abuse in 1 (Patient #2) of 1 patient reviewed who was accused of committing a sexual assault while being treated as an inpatient.

E) develop processes to ensure that staff who were terminated after confirmed abuse against a vulnerable population (children who are psychiatric patients) were reported to appropriate agencies as required by state regulation in 2 staff (Staff #25 and Staff #26) of 2 who were confirmed to have physically struck patients (battery).

Cross Refer to Tag A0145

Based on review of records and interview, the facility failed to

A) protect vulnerable behavioral health patients from physical and emotional trauma. Review of 27 patients (Patient #'s 1, 2, 4, 6, 7, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 22, 23, 24, 25, 26, 27, 28, 29, 30, 32, and 33 ) of 27 patient incident reports revealed that patients who were victims of, or witnesses to traumatic incidents, did not receive appropriate identification and interventions related to traumatic or harmful experiences that occurred during their stay in the facility.

B) aggregate, track, trend, and analyze data from violent, aggressive, and assaultive behaviors reported through the incident reporting system, TRIDEO, to improve patient safety and outcomes.


Findings for A included:

A review of Patient #2's chart and incident reports revealed the following:

Patient #2 was an adolescent that was admitted to the facility on 1-16-2020 and discharged on 1-28-2020 for a 12-day length of stay. During the patient stay, patient reported that he had suffered physical and psychological abuse by family members, with a Family Protective Services report of abuse filed.

During his stay, records show that on 1-24-2020 the patient assaulted a male peer after the male peer provoked him, calling him a "bitch and an asshole".

On 1-27-2020, the patient was a witness to an attack on a female patient that had coordinated and carried out by three other female peers. The patient was reported to be anxious about the events.

On 1-28-2020, Pt #2 was assaulted by his roommate. The Psychiatric Progress note dated 1-28-2020 at 11:47 documented the following physician note, "Pt was attacked by his new roommate who accused him of sexually assulting (sic) him this am".

Review of Patient #2's treatment plan showed that the Master Problem List had been updated to include the physical hold required from the 1-24-2019 incident. No short-term or long-range goals were found that corresponded with this new problem. There was not a treatment plan review and update completed until 1-27-2020 and did not include Problem E related to needing a physical restraint.

The treatment plan did not include any problem/treatment goals related to traumatic events experienced by the patient prior to entering inpatient care and experienced while receiving inpatient care in the BHC.

Patient #2 was assaulted by his roommate on 2-28-2020 at 10:45 AM and discharged at 1:45 PM the same day without the facility providing any screening or treatment for trauma as a result of being assaulted.

Traumatic events were defined as "exposure to actual or threatened death, serious injury, or sexual violence" in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (American Psychiatric Association, 2013).


A review of the incident reports for the Behavioral Health Center (BHC) for incidents of aggressive, violent, or assaultive behaviors that occurred between 12-15-2019 through 2-18-2019 was made. These types of events as defined by the DSM-5 meet the criteria for exposure to actual or threatened serious injury. Unit 100 was a unit that housed children. Unit 200 housed adolescents.

The following 61 were reported between 12-15-2019 through 2-18-2019 on the children's unit, Unit 100. Of the 61 reports, 35 were reports on Pt #24, to include a nurse physically assaulting Pt #24. These were reported between 12-17-2019 and 1-24-2020. Additional reports were made regarding the victims of Pt #24's attacks.

1. On 2-15-2020, "Nurse attempted to redirect patient (Pt #18) with verbal / therapeutic communication became aggressive and informed nurse, "Stop telling me what to do before I hit you, I can say and do whatever I want to . Patient became more aggressive AEB (as evidenced by): Yelling, screaming," (sic)
2. On 2-11-2020, Pt #9 "was placed in restraint chair due to harmful behaviors to himself; such as hitting head and arms on wall, Throwing (sic) items at peers and staff, posturing to strike a peer and imminent danger to self and others.
3. On 2-9-2020, Pt #9 "became agitated due to another patient bothering him and stated, "I just want to punch someone." Then he began chasing the patient in an attempt to punch him. He was put into a physical hold per SAMA (Satori Alternatives to Managing Aggression) technique and was released in 3 min."
4. On 2-4-2020, "Male peer pushed a chair on patient's (Pt #7) LT foot. LT little toe slightly reddened with discoloration on bottom of toe. C/O (complain of) pain when moving toe."
5. On 1-29-2020, Pt #19 "picked up a plastic bucket full of markers and threw the bucket towards this patient's (Pt #20) head and hit patient in the right forearm causing a small <1 in scratch. Pt denied pain. No wounds, skin breakage, or bleeding at site."
6. On 1-29-2020, Pt #19 "had a brown marker in her hand and stabbed this patient (Pt #7) in the abdomen with the marker. The patient felt a little pain but was upset her favorite shirt had a large brown ink blot on it."
7. On 1-29-2020, Pt #19 "came up to this patient (Pt #21) and hit patient in the face twice with a brown marker. Patient verbally said "ouch". This RN went to patient to check on him and he said where she hit him hurt. Patient has visible brown marker on his face."
8. On 1-29-2020, Pt #22 "attempted to hit and scratch peers for unknown reason. There did not appear to be any provocation. Became combative towards staff. She was placed in physical hold per SAMA, then placed in quiet room."
9. On 1-29-2020, Pt #19 began throwing shoes at staff and hitting staff with shoe, then hit peer and staffed 2 peers with markers, then dumped a box of markers on the floor and threw the empty box at a peer. She was restrained and placed in restraint chair."
10. On 1-29-2020, Pt #19 "posturing towards peers and attempted to hit staff. Patient was placed in a physical hold for the safety of the other children on the unit, the patient, and the staff."
11. On 1-27-2020, Pt #23's "behavior began to escalate after peers came back from dinner. She didn't want to take turns playing game and began throwing game pieces, call names (butt face) and hitting at peers."
12. On 1-27-2020, Pt #22's "behavior escalated after prn (as needed) atarax 5mg given. She was verbally aggressive, combative, hitting, kicking and screaming at staff. Pt laid down on the floor in doorway and refused to move. When staff tried to assist, she kicked and slapped."
13. On 1-24-2020, Pt #12 "combative behavior, hitting, kicking, head butting staff and spitting on staff, required physical hold and restraint chair"
14. On 1-24-2020, Pt #24 "became aggressive chasing other pt's and trying to bite them,staff redirected her and bit staff on left wrist requiring physica hold as pt.unable to be redirected (sic)."
15. On 1-24-2020, "At approximately 0753 (7:53 AM) patient (Pt #24) bit unit 100 tech ______ (staff name) while being held in a physical hold preventing the patient from chasing and potentially causing harm to another patient. The bit (sic) did break the skin. Tech _______ (staff name) had cleaned the wound and properly (sic) covered it."
16. On 1-21-2020, "female peer bit this pt (Pt #22) on the right upper arm.
17. On 1-21-2020, "This pt (Pt #24) ran up to a peer who was sitting at a table with others playing cards, and bit her on the right upper arm."
18. On 1-20-2020, Pt #24 "a patient on unit 100 was sitting in day room coloring and got upset and bit two different patients with code # _____ (patient code number) and code # _____ (patient code number) on their right forearm. patient got upset due to other patient not wanting to play with her. (sic)"
19. On 1-20-2020, Pt #25 "was bit by another patient code # _____ (Pt #24's code number) suddenly without any reason. Patient right forearm red and a spot with open skin about 1/10th inches observed to be open."
20. On 1-20-2020, Pt #22 "was suddenly bit by another patient code # _____ (Pt #24's code number) without any cause on her right forearm. The area is noted to be red but open skin observed (sic)."
21. On 1-17-2020, Pt #24 "was hitting, kicking, and biting staff."
22. On 1-15-2020, Pt #19 "was hitting, kicking, and spitting on staff. Pt went from a Physical Hold to Restraint Chair."
23. On 1-15-2020, Pt #26 "broke weather stripping from door jumping on sink and window sill in room kicking doors placed in physical hold"
24. On 1-15-2020, Pt #24 "became increasingly hyperactive, patient then impulsively became physically aggressive attempting to bite, kick, hit, and spit on peers and staff"
25. On 1-14-2020, Pt #26 "attempting to bust out window in his room, hitting, throwing himself against it, hitting his head, combative, throwing shoes at window and staff,"
26. On 1-12-2020, Pt #19 "was bitten by another pt. No injury noted. No redness or skin tear. Denies c/o (complaint of) pain."
27. On 1-12-2020, Pt #24 "bit another pt. and kicked and attempted to bite staff. Pt placed in physical hold per SAMA, then in restraint chair."
28. On 1-11-2020, Pt #24 "was biting, kicking, hitting staff and was in room jumping off of toilet. Patient was offered different things such as sitting for quiet time, beverage, to no prevai" (sic)
29. On 1-9-2020, Pt #19 "was sitting in dayroom and an aggressive younger peer picked up a book before staff could stop the child and the book was thrown at the patient striking her on the left arm and shoulder."
30. On 1-9-2020, Pt #24 "threw a book striking a peer, patient was screaming, hitting, kicking, and attempting to bite staff, standing on a table in the dayroom, would not redirect ..."
31. On 1-9-2020, Pt #24 was placed in a physical hold. "Patient was hitting staff and would not redirect and then patient aggressively postured toward other children on the unit."
32. On 1-9-2020, Pt #24 "was hitting, kicking, biting, and unsafe behavior by climbing on window ledge, patient was placed in a physical hold to protect patient, staff, and other children ..."
33. On 1-7-2020, Pt #27, "Aggressive pt was running towards new pt with intent to strike him. Aggressive pt was deflected by staff before any damage was done but bi-standing pt was grazed on the ear. No injury noted, but pt was visibly shaken."
34. On 1-7-2020, Pt #24 "was chasing patient ________(patient code number) around a table in the dayroom and when she cornered the other patient, patient ________(patient code number) turned to face her put her hands up to block patient from hitting her and patient fell backwards hitting her head."
35. On 1-6-2020, Pt #24 "suddenly started attacking another peer and staff. She was taken to quiet room to calm down. Patient threw herself on the floor hit her heel on the wall and floor, getting combative with staff attempting to stop the behavior."
36. On 1-6-2020, Pt #24 "is hitting, kicking, spitting and pulling staff hair. Physical hold to restraint char applied for safety."
37. On 1-6-2020, Pt #24 "Physical hold performed due to patient not redirectable, climbing on window ledge, due to unsafe behavior."
38. On 1-5-2020, Pt #24 "climbing on window ledge, unresponsive to verbal intervention by staff for patient safety, patient removed from window ledge and place in physical hold."
39. On 1-5-2020, Pt #24, "Physical hold applied for safety after pt would not redirect climbing onto window ledge. No injuries obtained."
40. On 1-5-2020, Pt #28 "was hit twice by a female peer an (sic) the peer became upset with patient and hit her twice."
41. On 1-2-2020, Pt #24 "was in group room turning over furniture, spitting, biting, hitting and kicking staff."
42. On 12-31-2019, Pt #24 punched Pt #33 in the nose.
43. On 12-31-2019, Pt #33 "was punched in the nose by _______ (Pt #24). Pt denies c/o pain. No bruises or injuries noted."
44. On 12-30-2019, Pt #24 "climbed on table in dayroom and was standing, staff assisted down from table, patient then struck a male peer and attempt to strike staff when staff intervened."
45. On 12-29-2019, Pt #24 "suddenly became aggressive towards peers and staff after peers came back from dinner. Patient started kicking, hitting, spitting and throwing objects, slamming the doors and running to another unit, refusing to be redirected."
46. On 12-26-2019, Pt #24 "climbing and standing on tables in dayroom, standing on water fountain in dayroom, would not redirect, high risk for falling with injury, patient hit MHT when redirection given, for patient safety patient was place in brief hold of 1 minute." (sic)
47. On 12-25-2019, Pt #24 "pounding at door between unit 100/200, yelling, burst through nurses station and thru door to unit 200, when stopped by MHT patient attempted to bite staff, combative, kicking, patient placed in a brief physical hold for patient and staff safety."
48. On 12-23-2019, Pt #24 "hit a male peer ________ (patient code number) on his facial area. ________ (patient code number) denies pain / denies discomfort no redness noted."
49. On 12-23-2019, Pt #30 "was slapped on (L) side of forehead by female peer. He stated that he was okay and denied c/o pain. No redness, bruising, or swelling noted."
50. On 12-21-2019, Pt #24 "began hitting, kicking, biting, and spitting at staff, patient would not redirect, patient was placed in a physical hold to restraint chair ..."
51. On 12-21-2019, Pt #24 "hitting and kicking female MHT monitoring patient on level 3 status. Placed in physical hold for pt safety."
52. On 12-21-2019, Pt #24 "performing unsafe behaviors, standing on table in dayroom almost falling and would not redirect to get down, for safety of the child, child was placed in brief physic" (sic)
53. On 12-21-2019, Pt #24, "0552 (5:52 AM) Pt began yelling out, running into other pt rooms and yelling at them. Pt not verbally redirectable at this time. Pt offered distraction, fluids, food. Pt yelled "f______ (curse word) you" at this RN and ran to day area and climbed onto table."
54. On 12-20-2019, Pt #24 "was in the dayroom, when she got up on the table she would not be redirected to get down, then she stepped off the table onto a chair and fell to the floor, no harm or injuries noted"
55. On 12-20-2019, Pt #24 "was hit on buttocks by a Nurse." (Staff #26 terminated for patient abuse)
56. On 12-19-2019, Pt #24 "was hitting and kicking and attempting to bite staff members during visitation. Another peer's mother was hit in the upper left back area by this patient. Patient removed to her room, and eventually given prn medication."
57. On 12-17-2019, Pt #32 "was acting out with unsafe behaviors towards staff and peers. Patient was placed in a brief hold.
58. On 12-17-2019, Pt #24 "had kicked a co-worker."
59. On 12-17-2019, Pt #24 "went in female peer's room. When staff asked her to leave peer's room, pt ran to peer and bit her on R forearm. Pt ran out of peer's room."
60. On 12-17-2019, Pt #29 approached nurses station crying. She stated that smaller peer bit her on the (R) forearm. Noted reddened circular area with slight bruising. No open areas noted to skin."
61. On 12-17-2019, Pt 24 "was pushed by male peer and fell on floor."


The following 23 aggressive, violent, or assaultive behaviors were reported between 12-15-2019 through 2-18-2019 on the adolescent unit, Unit 200.

1. On 2-15-2020, Pt #11 "instructed staff something her peers were doing, peers got angry with this patient, patient went to her room and punched the wall small bruise without swelling noted to right small finger knuckle."
2. On 2-3-2020, Pt #6 "states she punched the floor after getting upset, minor bruising and swelling to area, ice pack applied, guardian notified and md notified (sic)"
3. On 2-2-2020, Pt #12 "became upset, went to room and began to hit plexiglass with Rt hand, then hit window in room with RT hand. Physical hold to restraint chair using SAMA technique. Small cut to RT pinkie finger, cleansed with soap and water with bandaid applied. (sic)"
4. On 2-2-2020, Pt #1 "became angry after he was told the rules on the unit related to the telephone, he then walked to the door and punched the window portion."
5. On 1-31-2020, Pt #1 "came from his room yelling and cursing. Patient hit the door to the group room and a window with right hand. Swelling and redness noted. Notified Dr. _______. (physician's name). New orders obtained."
6. On 1-31-2020, Pt #1 became angry after speaking with his mother and punched the water machine. Patient does have edema noted to R hand. (sic)"
7. On 1-29-2020, Pt #1 "hit housing for fire extinguisher x 4 after argument on phone with mother."
8. On 1-28-2020, Pt #2 'reports he walked into his room and his roommate (male peer) wakes up and states "what are you doing?" ' Patient #2 was assaulted by Pt #1.
9. On 1-28-2020, Pt #1 "punched peer to left side of the face. Patient left room and went into group room patient threw a chair against a mounted painting on the wall, no damage noted to property or self, patient able to be talked to and calmed down. (sic)"
10. On 1-26-2020, Pt #13 "physically assaulted by female peers- hit, kicked. Staff intervened. MD and guardian notified. Order received to send pt to ER for evaluation. (sic)"
11. On 1-26-2020, Pt #14 was "put into a physical hold to mechanical restraint." Pt #14 was involved in the physical assault on Pt #13.
12. On 1-26-2020, "At approx. 2030 (8:30 PM) a coordinated assault took place with patient (Pt #15) and two co aggressors against a female peer. Patient attempted to attack patient but was placed in a physical hold."
13. On 1-26-2020, Pt #4 "put in physical hold after patient attacked a female peer. Patient hit and kicked peer while this writer was restraining another female patient for attacking the same female peer. The assault was coordinated by several patients."
14. On 1-26-2020, "At about 20:30h (8:30 PM) a physical altercation happened on the unit and __________ (Pt #2) felt anxious about the situation. He avoided the altercation and went near the nurses station. He was seen messing with his bandage and intentionally removed the cast from his left arm."
15. On 1-24-2020, Pt #15 threatened to attack a female peer. House Supervisor ___________ (staff name) attempted to talk down patient. Patient was not responding to staff talking to her. After approx. 5 minutes of patient talking to staff patient tried to shove through staff to attac"(sic)
16. On 1-24-2020, Pt #10 was assaulted by male peer in the unit 200 dayroom. Patient claimed that the peer was not provoked before being attacked. Peer hit patient in ear before staff restrained peer. Patient reported having a headache after the assault."
17. On 1-24-2020, Pt #2 assaulted a male peer. Per Pt #2 the peer had provoked the attack by calling him a "bitch and an asshole."
18. On 1-23-2020, Pt #4 became angry after hearing a staff member mention her name to another nurse. Went to room and punched wall. RN noted swelling and bruising to R hand. Full ROM. Ice pack given."
19. On 1-20-2020, Pt #16 "on phone with mother, slammed the phone down and ran into room, slammed door, loud bang heard x3." "patient punched wall with both hands x3 times."
20. On 1-20-2020, Pt #4 "approached nurse's station stating she hit the wall because her mother does not want her"
21. On 1-15-2020, Pt #4 "said she punched the wall. Her right hand was checked. No redness was seen. Patient was able to move her hand normally."
22. On 1-12-2020, Pt #4 "punched the wall in her room due to anger."
23. On 12-16-2019, Pt 17 "went into room, slammed door, and hit wall with both fists." Pt #17 stated, "They made me mad in the dayarea. (sic)"


On the morning of 2-28-2020, an interview was conducted with Staff #5, Quality Manager, and Staff #19, Risk Manager, at the main hospital campus. When asked who provides oversight and review of incidents entered into the event reporting system, TRIDEO, Staff #19 stated that Staff #22 had been trained as the Risk Manager at the Behavioral Health Center (BHC) on entering and investigating incidents and occurrences. When asked who at the main campus provided oversight and review of events to ensure they were being properly reported, investigated, tracked and analyzed, Staff #19 stated that it was all done through Staff #22 at the BHC. Staff #22 was responsible for reporting safety concerns through the daily safety huddle and quality indicators through quality meetings. Staff #19 was asked about an incident on 1-29-2020 where Patient #7 had been assaulted by another patient and her favorite shirt damaged. The TRIDEO reporting indicated that there was "No harm" to patient. Staff #5 was asked how the psychological trauma of being attacked without warning in a place that should be safe was being recorded and addressed. Staff #5 confirmed that only physical injuries were reported as harm.

On the morning of 2-19-2020, an interview was conducted with Staff #3, Staff #18, Staff #22, Staff #24, and Staff #28. When asked how patients who were witnesses or victims of traumatic events while receiving treatment in the BHC were screened and provided treatment for potential trauma related exposure, Staff #24 confirmed that there was not a process or program to help address and mitigate such exposure.


Review of a study titled Patients' Reports of Traumatic or Harmful Experiences Within the Psychiatric Setting, identified how traumatic events experience by psychiatric patients in the inpatient setting were harmful. Review was as follows:

"Discussion
This study provides strong empirical support for concerns raised by consumer and advocacy groups about patient safety within psychiatric settings. In a sample of patients with severe mental illness who were served by a public mental health clinic, high rates of lifetime trauma occurring within psychiatric settings were reported, including physical assault (31 percent), sexual assault (8 percent), and witnessing traumatic events (63 percent). In addition to events that met DSM-IV criteria for trauma, high rates of potentially harmful experiences were reported, such as having medications used as a threat or punishment (20 percent), being called
names by staff (14 percent) or hearing staff call other patients names (19 percent), and being around frightening or violent patients (54 percent). Also rates of institutional measures of last resort were high, including seclusion (59 percent), restraint (34 percent), takedowns (29 percent), and handcuffed transport (65 percent). These data also demonstrate that both traumatic and harmful experiences were associated with psychological distress.
...

Conclusions
Results suggest that traumatic and harmful experiences within psychiatric settings warrant increased attention from mental health administrators, supervisors, and clinicians. We encourage key stakeholders in public sector mental health systems to engage in discussion about policies, procedures, and training efforts; to be responsive to consumer initiatives; to reconsider administrative policies regarding seclusion and restraint; and to be sensitive to issues related to trauma in order to ensure that psychiatric settings provide care that is safe, dignified, and humane.

Acknowledgments
This work was partially supported by grants MH-01660 and MH-65517 from the National Institute of Mental Health."
https://pdfs.semanticscholar.org/5a40/db1b52da7d89686042bdc2411c423e77466c.pdf?_ga=2.54231083.2025846027.1583962722-89649271.1583962722


Findings for B) included:

Review of the EOC/Safety Committee Minutes from 2-12-2020 showed that Security Management section contained information on Year to date workplace violence information. Outcomes and Next Steps section contained the following statement, "Trending is normal in most areas, but combative patients seem to remain a constant."

No evidence of actual data regarding violent, aggressive, or assaultive incidents was presented in the minutes to show what had been trended, what the benchmark for normal was, or if problems with combative patients were being aggregated, tracked, trended, analyzed for patterns, and any new strategies would be put in place to improve patient safety outcomes.

Review of the section for the BHC report showed that Staff #22 had not reported any information on violent, aggressive, or assaultive incidents or how they were being tracked, trended, and analyzed or any results of such monitoring for safety improvement.

Staff #5 was asked who reviewed and approved the quality indicators that were being tracked at the BHC. Staff #5 reported that those indicators would be selected by management staff at the BHC and reported through the scheduled Department Reporting to the Quality Committee. Staff #22 was only required to report to the Quality Committee annually. BHC was scheduled to report again in June 2020. The last report was in August 2019. Review of the report presented by Staff #22 showed that only 4 indicators were selected for Performance Improvement (PI) activities. Those were:

Restraints and Seclusions
Elopements
Falls
Contraband

Review of the section on restraints and seclusion (to be used when a patient is a danger to self or others) only provided information for the months of June and July. Aggregated and analyzed data for the 12 months of reporting with trends was not presented.

Under "Identifiable risks:" Staff #22 presented that "treatment plans are followed, prescribed medications are administered and therapy sessions are provided." No information was presented on the evaluation of treatment plans, medications, and therapy sessions as they related to patient behaviors to determine if they were being properly adjusted, or if there were other options that available that had not been considered.

When asked for the Quality Assessment/Performance Improvement reporting and activities for the BHC during the 4th Quarter of 2019, a report on the Education and Audits for Follow Up Items of Regulatory Fall 2019 Visits was presented. This information did not contain Quality Indicators of PI projects related to reducing the amount of violent and aggressive activity in the BHC.

On the morning of 2-19-2020, an interview was conducted with Staff #3, Staff #18, Staff #22, Staff #24, and Staff #28. Staff #22 confirmed that he did not have data regarding violent, aggressive, or assaultive incidents to show what had been trended, what the benchmark for normal was, or how information was being aggregated, tracked, trended, analyzed for patterns such as day of week, time of day, staff involved etc.

Based on review of records and interview, the facility failed to:

A) prevent vulnerable patients who were being treated in an inpatient psychiatric setting at the Behavioral Health Center (BHC) from violent, aggressive, and assaultive behaviors of other patients in review of 27 patients (Patient #'s 1, 2, 4, 6, 7, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 22, 23, 24, 25, 26, 27, 28, 29, 30, 32, and 33 ) of 27 patient incident reports.

B) investigate allegations of sexual abuse in 1 (Patient #2) of 1 patient reviewed who was accused of committing a sexual assault while being treated as an inpatient.

C) develop processes to ensure that staff who were terminated after confirmed abuse against a vulnerable population (children who are psychiatric patients) were reported to appropriate agencies as required by state regulation in 2 staff (Staff #25 and Staff #26) of 2 who were confirmed to have physically struck patients (battery).

Findings for A) included:

A review of the incident reports for the Behavioral Health Center (BHC) for incidents of aggressive, violent, or assaultive behaviors that occurred between 12-15-2019 through 2-18-2019 was made. These types of events as defined by the DSM-5 meet the criteria as traumatic events for exposure to actual or threatened serious injury. Unit 100 was a unit that housed children. Unit 200 housed adolescents.

Cross Refer to Tag A0144 for detailed description of incident reports.

There were 61 reported incidents between 12-15-2019 through 2-18-2020 on the children's unit, Unit 100. Of the 61 reports, 35 were reports on Pt #24, to include a nurse physically assaulting Pt #24.

There were 23 aggressive, violent, or assaultive behaviors were reported between 12-15-2019 through 2-18-2020 on the adolescent unit, Unit 200. Patient #1 and Patient #4 had 5 reports each made. Patient #4 was responsible for coordinating with 2 other patients a physical and violent assault of a female peer that resulted in the peer needing to be transferred to the main campus emergency department for evaluation.

On the morning of 2-19-2020, an interview was conducted with Staff #3, Staff #18, Staff #22, Staff #24, and Staff #28. Staff #22 confirmed that he did not have data regarding violent, aggressive, or assaultive incidents to show what had been trended or how information was being aggregated, tracked, trended, analyzed for patterns such as day of week, time of day, staff involved etc. Staff #22 confirmed that this information was not provided to the Patient Safety Committee or the Quality Assessment / Process Improvement Committee.

Staff #22 confirmed that there was not a PI project in place to identify ways to protect patients from other violent and aggressive patients. Review of report provided to the Quality Assessment Committee for BHC at the last report on 8-5-2019 showed that "Performance improvement will be focused on the 4 primary indicators that are trended at BHC:
1) Restraints and Seclusions,
2) Elopements
3) Falls
4) Contraband"

Reducing restraints and/or seclusions would be one component of protecting patients from violence, aggression, and assault. However, not every act of aggression, violence, or assault resulted in a restraint and/or seclusion. Since the incidents of violence, aggression, and assault were not being aggregated, tracked, trended, and analyzed, actions to be taken to reduce them could not be effectively formulated.

Findings for B) included:

A review of Patient #2's chart and incident reports revealed the following:

Patient #2 was an adolescent that was admitted to the facility on 1-16-2020 and discharged on 1-28-2020 for a 12-day length of stay.

Per family therapy notes from 2-23-2020, the patient and his mother both expressed concerns about him returning home and harming the children. The patient also reported continued auditory and visual hallucinations.

Per Clinical Notes Report on 1-28-2020, "Spoke with _________ (Patient #2)'s CPS case worker regarding concerns related to him returning home after making statements that he would kill himself and his family on Friday 01/24/2020 as well as the morning of 01/27/2020 to his probation officer.

On 1-28-2020, Pt #2 was assaulted by his roommate. The Psychiatric Progress note dated 1-28-2020 at 11:47 documented the following physician note, "Pt was attacked by his new roommate who accused him of sexually assulting (sic) him this am".

Patient #2 was discharged home on 1-28-2020 at 1:45 PM, where he had access to two small children, ages 2 and 3. No evidence was found that showed an investigation into the allegations made against Patient #2 had been initiated, that CPS had been made aware of the allegations made against Patient #2, or that Patient #2's mother had been made aware of the sexual assault allegations made by the patient's roommate.

Review on the incident reporting system, TRIDEO, did not include an incident for the allegations made against Patient #2 of sexual assault, with subsequent investigation documented. Allegations of sexual assault, if true, would be considered a Reportable Event per the National Quality Forum (NQF) guidelines. However, if allegations were never reported and investigated to determine the non-existence or existence of an assault, an environment that was unsafe for patients could continue to exist.

A review was made of the policy, Subject: BHC/Patient Abuse and Neglect, Policy Code: 1600.203, Effective Date 09/04/94 that was provided by the facility. Review was as follows:

"POLICY:
It is the policy of ETMC Behavioral Health Center to report and investigate all incidents of possible or suspected abuse or neglect. Forms of abuse may include, but not limited to, physical, verbal, psychological, sexual, or personal/financial exploitation. Each employee who suspects or has knowledge of, or who is involved in possible abuse or neglect is responsible for reporting the situation to the Nursing Director and Administrator/Designee within one (1) hour of the occurrence. The Administrator will contact the Risk Manager to begin the investigation and follow the mandatory reporting when indicated. ...

PROCEDURE:

General Duties and Responsibilities of the Nursing Director/House Supervisor

Immediately upon receipt of notification of an allegation of abuse or neglect, the supervisor will: ...

With the appropriate consent, notifies the patient's designated contact (family or other), parent, or guardian of the allegation and the process for addressing the alleged incident. If the patient(s) involved is a minor, no consent is needed to notify the parent(s) or guardian as it is a mandatory requirement. ...

If the allegation involves physical or sexual abuse, the supervisor will, as indicated:
Secure the alleged location of the incident.
Assess the victim for evidence of injury to include photos depicting the existence or non-existence of injuries and secure physician order for SANE exam if it is an alleged sexual assault
Secure the statements of both the alleged victim and individual accused of the abuse."



Review of policy, Title; Serious Adverse Event Reporting-QM-Corp; Policy Number 30675.1; Division Approval Date: 09/25/2019, was made as follows:

"Purpose:
Adverse Events take a significant toll on our patients as well as our healthcare system. This policy is for guidance on defining, communicating, assessing and acting upon serious adverse events as well as to support prevention and improvement of patient care.

Policy:
1) Any adverse event which potentially meets the definition of the National Quality Forum's Serious Reportable Events, The Joint Commission's Sentinel Event or other Serious Adverse Events (see definitions) should be reported as soon as possible to the facility Risk Manager.
2) The Risk Manager is responsible for notifying appropriate internal personnel within 48 hours ..."

Review of National Quality Forum's (NFQ) Serious Reportable Events, retrieved from https://www.ncbi.nlm.nih.gov/books/NBK20598/ was as follows:

"The NQF-endorsed consensus list of 27 serious reportable events that should be reported and investigated by all health care facilities if they occur. The events are organized in six categories-five that relate to the provision of care (i.e., surgical, product or device, patient protection, care management, and environmental) and one category that includes four criminal events. These latter events involve illegal acts, or acts of misconduct, and are included because they could be indicative of an environment that is unsafe for patients. Although health care facilities cannot eliminate all risk of these events, they can take preventive measures to reduce their risk of occurrence.

...

6. Criminal events

A. Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed health care provider

B. Abduction of a patient of any age

C. Sexual assault on a patient within or on the grounds of the health care facility

D. Death or significant injury of a patient or staff member resulting from a physical assault (i.e., battery) that occurs within or on the grounds of the health care facility"


Findings for C) included:

During the review of incidents at the BHC, it was determined that Staff #25 and Staff #26 no longer worked at the facility after incidents with patients.

A review of investigations and personnel files for Staff #25 and Staff #26 revealed that both were Registered Nurses who committed substantiated acts of battery against patients.

On 8-24-2019, Staff #25 was confirmed to have been in a verbal exchange with an adolescent patient who was being treated at the BHC for her mental illness. The patient became angry with the Staff #25 when he allegedly called her vicious. The patient grabbed a cup of liquid and threw it on Staff #25. Staff #25 retaliated by throwing a cup of liquid on the patient.

On 12-20 2019, Staff #26 was confirmed to have hit a child on the bottom. The child was a patient being treated for mental illness on the children's unit (Unit 100) of the BHC.

No evidence was found in either staff member's file of mandatory reporting to the Texas Board of Nursing.

Review of the Texas Occupations Code, Title3. Health Professions, Subtitle E. Regulations of Nursing, Chapter 301. Nurses; Subchapter A. General Provisions (referred to as the Nurse Practice Act) was as follows:

"Sec. 301. 401.DEFINITIONS. In this subchapter:
(1)"Conduct subject to reporting" means conduct by a nurse that:
(A)violates this chapter or a board rule and contributed to the death or serious injury of a patient;
(B)causes a person to suspect that the nurse 's practice is impaired by chemical dependency or drug or alcohol abuse;
(C)constitutes abuse, exploitation, fraud, or a violation of professional boundaries; or
(D)indicates that the nurse lacks knowledge, skill, judgment, or conscientiousness to such an extent that the nurse 's continued practice of nursing could reasonably be expected to pose a risk of harm to a patient or another person, regardless of whether the conduct consists of a single incident or a pattern of behavior.

...

Sec. 301. 402. MANDATORY REPORT BY NURSE.
(a) Repealed by Acts 2007, 80th Leg., R.S., Ch. 803, Sec. 21(3), eff. September 1, 2007.
(b) A nurse shall report to the board in the manner prescribed under Subsection (d) if the nurse has reasonable cause to suspect that:
(1) another nurse has engaged in conduct subject to reporting;

...

Sec. 301. 402. MANDATORY REPORT BY NURSE.
(a) Repealed by Acts 2007, 80th Leg., R.S., Ch. 803, Sec. 21(3), eff. September 1, 2007.
(b) A nurse shall report to the board in the manner prescribed under Subsection (d) if the nurse has reasonable cause to suspect that:
(1) another nurse has engaged in conduct subject to reporting; ... "

Sec. 301.405. DUTY OF PERSON EMPLOYING NURSE TO REPORT. (a)
This section applies only to a person who employs, hires, or contracts for the services of a nurse, including:
(1) a health care facility, including a hospital, health science center, nursing home, or home health agency;
(2) a state agency;
(3) a political subdivision;
(4) a school of nursing; and
(5) a temporary nursing service.
(b) A person that terminates, suspends for more than seven days, or takes other substantive disciplinary action, as defined by the board, against a nurse, or a substantially equivalent action against a nurse who is a staffing agency nurse, because the nurse engaged in conduct subject to reporting shall report in writing to the board:
(1) the identity of the nurse;
(2) the conduct subject to reporting that resulted in the termination, suspension, or other substantive disciplinary
action or substantially equivalent action; and
(3) any additional information the board requires.
(c) If a person who makes a report required under Subsection (b) is required under Section 303.0015 to establish a nursing peer review committee, the person shall submit a copy of the report to the nursing peer review committee. The nursing peer review committee shall review the conduct to determine if any deficiency
in care by the reported nurse was the result of a factor beyond the nurse 's control. A nursing peer review committee that determines that there is reason to believe that the nurse 's deficiency in care was the result of a factor beyond the nurse 's control shall report the conduct to the patient safety committee at the facility where
the reported conduct occurred, or if the facility does not have a patient safety committee, to the chief nursing officer.
(d) Repealed by Acts 2007, 80th Leg., R.S., Ch. 803, Sec. 21(4), eff. September 1, 2007.
(e) The requirement under Subsection (c) that a nursing peer review committee review the nurse and the incident does not subject a person 's administrative decision to discipline a nurse to the peer review process.

..."

An interview was conducted with Staff #3, Chief Nursing Officer, on 2-18-2020. Staff #3 stated she was not aware that Staff #26 had been terminated because of confirmed patient abuse. Staff #3 had not been in place as Chief Nursing Officer when Staff #25 had been terminated.

Review of a list of staff who were no longer employed by the hospital showed that Staff #26 was a voluntary termination (indicating the staff had resigned) on 12-30-2019. Review of Staff #26's employee file indicated the Staff #26 was eligible to be rehired, even though she had been confirmed to strike a child in her care. Staff #3 stated that the Director of Nursing at BHC had not made her aware that a nurse was being terminated for cause.

Staff #3 was asked why she would not have known about Staff #26 striking a child when an event had been reported in the TRIDEO system. Staff #3 stated that the event should have been reviewed and discussed during the daily safety huddle meeting, but that Staff #22 had not reported and discussed the event. Staff #3 confirmed that since the event had been reported as a "Professional caregiver conduct" that resulted in "No harm", it had not triggered the other members of the daily safety huddle to review it.

An interview was conducted on 2-18-2020 at approximately 2:40 PM with Staff #21 who managed Human Resources (HR) files at BHC. Staff #21 stated she did not get involved with issues concerning disciplinary actions or terminations other than processing paperwork. Staff #21 reported that Staff #26 had been brought in to be terminated but stated she was resigning. Staff #21 stated that the decision to allow her to resign and mark her as eligible for rehire would have been made by either Staff #22 or Staff #28.

Interview was conducted was conducted on the morning of 2-19-2020 with Staff #3 Chief Nursing Officer, Staff #22 Risk Manager, and Staff #28 Director of Nursing. Staff #28 stated that she had contacted Staff #23, at the main hospital HR department. Staff #28 stated that Staff #23 told her she did not have to report Staff #25 to the Texas Board of Nursing.

Staff #22 was asked why he had allowed Staff #26 to resign instead of terminating her. Staff #22 stated that Staff #26 had cooperated with the investigation and was "remorseful". When he brought her in to tell her the allegations of patient abuse had been substantiated and she was being terminated, Staff #26 states she was resigning. Staff #26 stated he contacted the main HR department and was told it would be OK to let her resign.

Staff #22 and Staff #28 both confirmed that they knew as registered nurses they were obligated to abide by the regulations set forth in the Nurse Practice Act. When asked why they had not made a mandatory reporting to the Texas Board of Nursing as required by the Nurse Practice Act, both indicated that they were not aware that they had been required to report.

The failure of the facility to exercise oversight of the information being reported by the BHC and events taking place at the off-site location, along with a lack of defined processes for the termination of professional staff for cause, allowed Staff #25 and Staff #26 the opportunity to be employed as nurses in the same type of care setting that both had been confirmed through facility investigation to have committed battery against a vulnerable population.

Based on observation, interview, and record review, the facility failed to:

A. ensure a sanitary environment for storage of sterile surgical supplies in 1 (Sterile processing staging area) of 1 areas observed.

B. ensure a sanitary/safe environment for storage of sterile surgical implants/instruments in 1 (Sterile processing staging area) of 1 areas observed.

C. ensure that sterile surgical sternum saw blades were reprocessed according to the manufacturer recommendations in 1 of 1 items observed.

D. ensure sterile orthopedic single use items were not placed back on the shelf and available for patient use after the seal to the package had been broken.


Findings Include:

During a tour of the Surgical Department on 2-18-2020 after 10:00 A.M. with Staff #8 the following observations were made:

A. SANITARY ENVIRONMENT FOR STORAGE OF STERILE SURGICAL SUPPLIES

STAGING AREA

There were torn cardboard boxes containing sterile Arthrex suture anchors used in arthroscope orthopedic cases. The staff were using the torn cardboard boxes to store multiple packages risking contamination to the sterile supplies.

There was a metal rack storing sterile instruments used in robotic surgeries. The sterile supplies were touching the back wall and hanging off the metal rack in the front. The sterile supplies were in an area with high traffic and were at risk of compromising the sterility of the package.

There were three packages of sterile Hydro Lemaitre Valvulotome (Sterile Supply used in vascular cases to cut valves) that were stored in between a metal rack and wall sitting on the chair rail of the wall.

There were bins that had sterile surgical supplies overstocked and the sterile supplies were touching the top of the metal rack above the bins. The packages were stored in a manner that could risk the packages to tears and holes compromising the sterility of the item.

Staff #7 confirmed findings on the sterile supply storage.


B. SANITARY ENVIRONMENT FOR STORAGE OF STERILE SURGICAL IMPLANTS AND INSTRUMENTS

STAGING AREA

There was a supply cart containing Synthes sterile Trochanteric reattachment device with cables (Orthopedic implant). The base of the cart drawer that stored the sterile supply was coated in dust, dirt, debris, trash, and rubber bands. There was an unsterile orthopedic instrument in the drawer with sterile implants.

In another drawer of the cart, there were sterile Synthes cables. The base of the drawer was coated in dust and rubber bands.

In the Wright medical bin there were sterile Radial Stem implants sitting in a drawer. The base of the drawer was coated in dust and rubber bands.

There was a bin containing Stryker sterile Condyle Screws and orthopedic implants. The base of the bin storing the implants was coated in dust, dirt, and debris.

There were peel packs (Surgical pouch used to sterilize instruments) stacked up and packed tightly in the bins. The bins had sterile peel packs of Orthopedic instruments, total knee trials, and total knee instruments. Some of the surgical packages contained instruments that were heavy and could easily tear and compromise the sterility of the package. During observation the surveyor found three sterilized packs of orthopedic instruments with a hole in the package. The instruments were on the shelf and available for patient use. The orthopedic instrument packages were stored in a manner that would allow the package to be crushed, bent or punctured thus compromising the sterility of the item.

There were two peel packed "Mako Extra" instruments that had brown colored water stains on the package. There was no way to ensure the sterility of the package.

Review of ANSI/AAMI S179:2017 - Comprehensive guide to steam sterilization and sterility assurance in health care Facilities (Engineering department) revealed the following:

"11 Storage and transportation

11.1 Sterile storage
11.1.l Storage Facilities (Engineering department)

Sterile items should be stored under environmentally controlled conditions in a manner that reduces the potential for contamination.

Sterile storage areas should be kept clean and dry.

Sterile items should be
1) stored far enough away from the floor, the ceiling, and outside walls to allow for adequate air circulation, ease of cleaning, and compliance with local fire codes;
2) stored at least 8 to 10 inches above the floor, at least 18 inches below the ceiling or the level of the sprinkler heads, and at least 2 inches from outside walls;
3) stored in such a way that wrapped packages are not stored beneath rigid sterilization containers on the same shelf; and
4) positioned so that packaging is not crushed, bent, compressed, or punctured and so that their sterility is not otherwise compromised."

Staff #7 confirmed findings on the sterile implant/instrument storage.

C. STERILE SURGICAL BLADE PROCESSING

In room 4 (Trauma Room) in a supply cart observed a Stryker sternum saw blade that was processed and sterilized in 2016. The blade was available for patient use. The sternum blade was in the same drawer with Stryker Sterile Single Use Sternum Blades. Staff #8 was asked to provide the manufacturer IFU for the blade processed in 2016.

In an interview on 2-18-2020 after 1:00 p.m., Staff #7 stated, "The blades from 2016 were not single use. They were sent unsterilized and we processed them at the facility. Staff #7 was asked if the facility had the IFU for processing the blade. Staff #7 confirmed they did not. Staff #8 stated, "We called Stryker, but they no longer have the IFU for reprocessing blades as this is no longer their practice."

There was no way to ensure the blade was processed according to manufacture guidelines. There was no way to ensure sterility of the blade.

Staff #7 confirmed the above findings.


D. STORAGE OF SINGLE USE IMPLANTS/SUPPLIES

STAGING AREA

Observed six (6) Stryker Single Use orthopedic implants in a plastic tube on a metal rack with a seal that read, "Do Not Use if Seal is Broken".

The following single use supplies had seals broken, end caps off and broken plastic tubes on the shelf and were available for patient use:

1. Two K-wires with washers
2. Three K-wires
3. One Fixation K-wire.


SURGICAL HALLWAY CYSTO CART

Observed partially used betadine bottle on the cart and available for patient use. The bottle label read, "Single Use when used for patient preoperative skin preparation."


Staff #8 confirmed the findings on the storage of single use supplies and implants.

Based on review of records and interview, the facility failed to ensure that 2 disciplines (Nursing and Social Work) of 3 disciplines were documenting progress notes as required.

Findings included:

On 2-19-2020, chart reviews were conducted with Staff #3, Staff #18, Staff #22, Staff #24, and Staff #28 present.

Review of Social Work notes to include treatment plan, group notes, individual therapy notes, and family notes, with Staff #24 acting as the navigator for Social Work notes, revealed that there were no progress notes found. When asked about progress notes, Staff #24 initially referred to the treatment notes for groups, individual, and family therapy. Upon review of those notes, Staff #24 confirmed that they did not give a chronological picture of how the patient was progressing towards meeting specific goals that had been established in the interdisciplinary treatment plan. It was confirmed that the notes did not contain recommendations for revision in the treatment plan as well as a precise assessment of the patient's progress in accordance with the original or revised treatment plan.

Review of nursing notes confirmed that that discipline also did not provide progress notes as they related to the patient's progress towards achieving the goals identified in the treatment plan. This was confirmed by Staff #22 and #28.