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UNIVERSITY OF MINNESOTA MEDICAL CENTER, FAIRVIEW 2450 RIVERSIDE AVENUE MINNEAPOLIS, MN 55454 Oct. 17, 2013
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on documentation review and interviews the hospital failed to protect 1 of 1 patient (P1) from abuse when nursing station technician (NST)-O hit P1 in the forehead with the call light while providing 1:1 supervision to P1. Findings include:Review of P1's medical record revealed the patient had diagnoses including Jefferson Type C1 Fracture after a fall at home, acute hypoxemic hypercarbic respiratory failure, right artery dissection, and ICU delirium. The patient was extremely agitated, flailing arms and legs, requiring medication changes, restraints and 1:1 supervision during his ICU stay. The patient was often unable to follow commands.

An interview was conducted with NST-O on October 17, 2013, at 2:13 p.m. and he stated during the night of August 4-5, 2013, NST-O was providing 1:1 supervision for P1. P1 was slinging his feet over the edge of the bed , very restless in bed and combative with staff and during the night there were up to 4-6 staff assisting P1. After P1 had settled, Nurse CC went to care for another patient and document. NST-O was holding the call light/television remote to find a channel P1 may like to watch to help him settle when P1 rolled over in bed, rolled back and punched NST-O in the stomach. NST-O struck P1 in the forehead with the call light/remote causing a bleeding laceration on P1's forehead. An interview with Nurse CC was conducted on October 1, 2013 at 7:56 a.m. Nurse CC said P1 was agitated, restless and combative with staff during the night as he usually was. Nurse CC was in P1's room with NST-O to monitor P1 for safety. Nurse CC verified with NST-O that he would remain with P1 and care for P1's needs while Nurse CC went to care for another patient and document. Nurse CC responded to the call light in P1's room. NST-O told Nurse CC that he hit P1 with the call light after P1 punched NST-O in the stomach. P1 sustained a bleeding laceration to his/her forehead. Nurse CC said she applied pressure and a dressing to the wound. Nurse CC reported the incident to Nurse DD immediately. A physician examined P1's wound. No treatment was necessary. An interview with Nurse DD was conducted on October 1, 2013 at 8:39 a.m. Nurse DD stated Nurse CC called her on the unit and told her that NST-O struck P1. Nurse DD removed NST-O from patient care and contacted the nursing administration. The human resource manager came to the unit and spoke with NST-O along with Nurse DD. NST-O stated he hit P1 with the call light after P1 punched him in the stomach. NST-O was sent home and not allowed to return to the hospital. An interview with Social Worker BB was conducted on October 2, 2013 at 12:33 p.m. Social Worker BB stated she received information about the incident with P1 and NST-O days later. She reported the incident three days after it occurred.

Review of the hospital policy and procedure related to Identification and Reporting Suspected Maltreatment of Vulnerable Adults, revised June 2011, revealed "I. Legal Requirement the Vulnerable adult Act (Minnesota Statute 626.557) requires a mandated reporter who has reason to believe that a VA is being or has been maltreated, or who has knowledge that a VA has sustained a physical injury which is not reasonably explained, to immediately report the information to the Common Entry Point (CEP)."

Review of the hospital Patients' Bill of Rights handbook revealed "2. Courteous Treatment Patients have the right to be treated with courtesy and respect for their individuality by employees of or persons providing services in a health care facility....11. Freedom from Maltreatment Patients shall be free from maltreatment as defined in the Vulnerable Adults Protection Act. "Maltreatment" means conduct described in MN Statute Section 626.5572, Subdivision 15, or the intentional and nontherapeutic infliction of physical pain or injury...." The hospital policy and procedure for Patient Rights and Responsibilities, approved January 2011, noted "Fairview's Responsibilities: Every patient at Fairview shall have all patient rights set forth by law, including, but not limited to, those that have been set forth by Minnesota State Law (Patient Bill of Rights....)" and "Definitions: Patient Bill of Rights: the compilation of patient rights set forth by Minnesota law regarding the patient bill of rights and access to health records, and the Federal law concerning the Hospital Conditions of Participation."