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FORT SANDERS REGIONAL MEDICAL CENTER 1901 W CLINCH AVE KNOXVILLE, TN 37916 June 2, 2016
VIOLATION: PATIENT RIGHTS Tag No: A0115
A complaint survey was conducted on May 9 through June 2, 2016, at Fort Sanders Regional Medical Center. Patient #2 was evaluated in the Emergency Department (ED) for a psychiatric evaluation. During the patient's admission to the ED, Patient #2 was physically assaulted by a security officer. The facility failed to provide care in a safe setting and failed to protect the patient from abuse.

Refer to Standard A144 and A145.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on facility policy review, medical record review, review of a facility video recording, and interview, the facility failed to ensure one patient (#2) received care in a safe setting of 5 patients reviewed.

The findings included:

Review of facility policy Alleged Assault or Abuse of Patients, last reviewed on 9/2013 revealed "...all patients have the right to be free from verbal...physical...corporal punishment...mistreatment...neglect...abuse are prohibited...if there is an allegation that a patient has been assaulted or abused...always treat it seriously...never brush off or ignore such an allegation...if the alleged perpetrator is a staff member...they must not have any further contact with the alleged victim..."

Medical record review revealed Patient #2 was admitted to the Emergency Department (ED) on 12/10/15 at 9:51 PM for a psychiatric evaluation. Continued review revealed the patient was placed in hall bed #1 (located across from the nurses' station) on arrival.

Medical record review of a nurse's note dated 12/11/15 at 2:00 AM revealed "...sitter at bedside...pt [patient] get up walks into second pts room...redirected to hall bed 1...pt walks into room 2...redirected...pt got up from bed walked down hallway...staff at side...redirected...security at bedside...pt tried to get up for fourth time...security asked pt to sit on bed...pt struck at security...pt placed in restraits [restraints] to protect pt..." Further review at 3:06 AM revealed "...pt ambulating in room...pt reports staff hit pt...reported to house supervisor..."

Medical record review of a physician's progress note dated 12/11/15 at 2:19 AM revealed "...I was called to bedside...per report from charge nurse patient had altercation with security officer...the officer reports that he struck the patient in the left jaw...patient has redness on left side of face on left mandible...not allowing me to evaluate the mandible..."

Medical record review of a physician's assessment dated [DATE] at 6:51 PM revealed "...DX [diagnosis]...left face contusion...inner mouth contusion..."

Review of a facility provided video recording dated 12/11/15 at 1:58:46 AM revealed Patient #2 was standing at the end of a stretcher located in the hallway across from the nurses' station. Continued review at 2:02:24 AM revealed the security officer walked up to the patient and pushed the patient, causing the patient to fall onto the hall stretcher. Further review at 2:02:26 AM revealed the patient stood up again at the end of the stretcher, swung his arm at the security guard without making contact, and then the security guard hit the patient on the left side of his face. Continued review revealed the patient fell on to the stretcher and appeared to have lost consciousness. Further review revealed the security guard and the ED sitter pulled the patient up onto the stretcher.

Interview with the Senior Risk Manager on 5/10/16 at 12:15 PM, in the conference room, revealed "...incident happened while the patient was in the hallway...it happened about 2:00 in the morning...house supervisor came down there sometime later...she didn't send him [security guard] home...anytime this happens...employee involved has to be gotten out of the situation...sent home immediately...ED employees have been told to have involved person leave...officer's contract was terminated...the video recording shows the security officer stepped back...hard to tell if the security guard was hit...it does show the patient was hit..."

Telephone interview with the House Supervisor on 5/10/16 at 2:14 PM revealed "...I do remember him...I got a telephone call from...nurse...told me the patient was causing a lot of problems...they called the security officer...[Patient #2] acted like he was going to punch the security officer in the groin...the security officer said it was a knee jerk reaction...he punched him in the jaw...it was shortly after the incident that I went down there...the patient was laying on the stretcher...the security officer was in the security office when I was there...I went to speak with him and he told me had spoken with his supervisor...I didn't know if I had the authority to send him home...I was new...now I know we would not let an employee continue to work if they are accused of abuse..."

Telephone interview with Registered Nurse (RN) #1 on 5/11/16 at 11:11 AM revealed "...I was charge [nurse] that night...he [Patient #2] tried walking out of the ER [emergency room ]...he was suicidal...we called security because he was trying to leave the ER...they [security] told him he couldn't leave...I didn't actually see the security officer hit him..."

Telephone interview with ED Tech #1 on 5/11/16 at 3:25 PM, revealed "...I was the sitter that day...I asked him [Patient #2] if he was hungry...got him something to eat...he got out of bed and was trying to walk...his behavior start escalating...I was standing behind security...security was at the bedside telling him he couldn't get up...I heard a lick [hit]...I saw blood coming out of his mouth...the patient did hit the security guard first...I heard 2 licks...the patient hit first...the security officer was just reacting...the patient hit him [security guard] in his private area...then the next thing I remember is all the staff coming to help...don't know where the security officer went..."

Interview with RN #2 on 5/26/16 at 3:13 PM revealed "...I was in the vicinity...didn't see what happened...I was sitting at the desk [nurses' desk] charting in the computer...it happened across from the desk...I just heard the sounds...contact of some sort...I looked up and saw some kind of commotion...didn't want to get involved...didn't know what happened...I knew there was a patient who was restless and becoming agitated...he wasn't my patient and I didn't want to get involved..."

Telephone interview with ED RN #3 on 6/1/16 at 2:34 PM, revealed "...I was at the nurses' station when it happened...he [patient] didn't want to stay...security got called...my back was to it...I heard it...sounded like hands were hitting...I turned around and the patient was laying on the bed...I left very shortly after that...my shift was over...don't know where the security guard went...if we see abuse...supposed to get the patient out of the situation..."

Interview with the Risk Manager on 5/10/16 at 9:30 AM, in the conference room, revealed "...the security guard was an employee of a contracted security company...he is no longer allowed to work here...we watched the video...it was determined he could never work for the [hospital system]..." Further interview confirmed the security officer hit the patient, the patient was not provided care in a safe environment, and the facility staff did not follow facility policy.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on facility policy review, medical record review, review of a facility video recording, and interview, the facility failed to ensure patients were free of abuse for one patient (#2) of 5 patients reviewed.

The findings included:

Review of facility policy Alleged Assault or Abuse of Patients, last reviewed on 9/2013 revealed "...all patients have the right to be free from verbal...physical...corporal punishment...mistreatment...neglect...abuse are prohibited...if there is an allegation that a patient has been assaulted or abused...always treat it seriously...never brush off or ignore such an allegation...if the alleged perpetrator is a staff member...they must not have any further contact with the alleged victim..."

Medical record review revealed Patient #2 was admitted to the Emergency Department (ED) on 12/10/15 at 9:51 PM for a psychiatric evaluation. Continued review revealed the patient was placed in hall bed #1 (located across from the nurses' station) on arrival.

Medical record review of a nurse's note dated 12/11/15 at 2:00 AM revealed "...sitter at bedside...pt [patient] get up walks into second pts room...redirected to hall bed 1...pt walks into room 2...redirected...pt got up from bed walked down hallway...staff at side...redirected...security at bedside...pt tried to get up for fourth time...security asked pt to sit on bed...pt struck at security...pt placed in restraits [restraints] to protect pt..." Further review at 3:06 AM revealed "...pt ambulating in room...pt reports staff hit pt...reported to house supervisor..."

Medical record review of a physician's progress note dated 12/11/15 at 2:19 AM revealed "...per report from charge nurse patient had altercation with security officer...the officer reports that he struck the patient in the left jaw...patient has redness on left side of face on left mandible...not allowing me to evaluate the mandible..."

Medical record review of a physician's assessment dated [DATE] at 6:51 PM revealed "...DX [diagnosis]...left face contusion...inner mouth contusion..."

Review of a facility provided video recording dated 12/11/15 at 1:58:46 AM revealed Patient #2 was standing at the end of a stretcher located in the hallway across from the nurses' station. Continued review at 2:02:24 AM revealed the security officer walked up to the patient and pushed the patient, causing the patient to fall onto the hall stretcher. Further review at 2:02:26 AM, revealed the patient stood up again at the end of the stretcher, swung his arm at the security guard without making contact, and then the security guard hit the patient on the left side of his face. Continued review revealed the patient fell on to the stretcher and appeared to have lost consciousness. Further review revealed the security guard and the ED sitter pulled the patient up onto the stretcher.

Interview with the Senior Risk Manager on 5/10/16 at 12:15 PM, in the conference room, revealed "...incident happened while the patient [#2] was in the hallway...it happened about 2:00 in the morning...house supervisor came down there sometime later...she didn't send him [security guard] home...anytime this happens...employee involved has to be gotten out of the situation...sent home immediately...ED employees have been told to have involved person leave...the video recording shows the security officer stepped back...hard to tell if the security guard was hit...it does show the patient was hit..."

Telephone interview with the House Supervisor on 5/10/16 at 2:14 PM revealed "...nurse...told me the patient was causing a lot of problems...they called the security officer...[Patient #2] acted like he was going to punch the security officer in the groin...the security officer said it was a knee jerk reaction...he punched him in the jaw...it was shortly after the incident that I went down there...the patient was laying on the stretcher...the security officer was in the security office when I was there...I didn't know if I had the authority to send him home...I was new...now I know we would not let an employee continue to work if they are accused of abuse..."

Telephone interview with ED Tech #1 on 5/11/16 at 3:25 PM, revealed "...I was the sitter that day...I asked him [Patient #2] if he was hungry...got him something to eat...he got out of bed and was trying to walk...his behavior start escalating...I was standing behind security...security was at the bedside telling him he couldn't get up...I heard a lick [hit]...I saw blood coming out of his mouth...the patient did hit the security guard first...I heard 2 licks..."

Interview with RN #2 on 5/26/16 at 3:13 PM revealed "...I was in the vicinity...didn't see what happened...I was sitting at the desk [nurses' desk] charting in the computer...it happened across from the desk...I just heard the sounds...contact of some sort...I looked up and saw some kind of commotion...didn't want to get involved...didn't know what happened...I knew there was a patient who was restless and becoming agitated...he wasn't my patient and I didn't want to get involved..."

Telephone interview with ED RN #3 on 6/1/16 at 2:34 PM, revealed "...I was at the nurses' station when it happened...he [Patient #2]] didn't want to stay...security got called...my back was to it...I heard it...sounded like hands were hitting...I turned around and the patient was laying on the bed...if we see abuse... supposed to get the patient out of the situation..."

Interview with the Risk Manager on 5/10/16 at 9:30 AM, in the conference room, revealed "...the security guard was an employee of a contracted security company...he is no longer allowed to work here...we watched the video...it was determined he could never work for the [hospital system]..." Further interview confirmed the security officer hit the patient and the facility staff failed to follow the facility's policy for abuse.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on facility policy review, medical record review, and interview, the facility failed to prevent the development of a pressure ulcer in one patient (#1) of 4 patients reviewed.

The findings included:

Review of facility policy Wound Management Program, last revised on 12/2012 revealed "...actions for risk assessment and prevention of Pressure Ulcers at the time of admission and during each subsequent shift...moderate risk...inspect skin every shift...the nurse must ensure patient is repositioning him/herself...implement turning schedule based on assessed need of patient..."

Medical record review revealed Patient #1 was admitted to the facility on [DATE] at 9:23 PM for diagnosis including Shortness of Breath, Acute Respiratory Failure, Pleural Effusion, and [DIAGNOSES REDACTED] with Metastatic Lesions to the Brain.

Medical record review of an admission skin assessment dated [DATE] at 5:00 AM revealed the patient's skin condition was normal (indicating no skin breakdown) and he scored a 14 (indicating moderate risk) on the Braden Scale for risk assessment. Continued review revealed the preventive interventions included "...frequent turning...turn q [every] 2 h [hours]...float heels..."

Medical record review of a physician's progress note dated 3/22/16 at 5:24 PM revealed "...pt [patient] was ambulating...had declined in physical fxn [function]...unable to ambulate..."

Medical record review of a physician's progress note dated 3/28/16 at 4:27 PM revealed "...try to get pt OOB [out of bed] to chair BID [twice daily]..."

Medical record review of a nurses shift assessment dated [DATE] at 6:15 PM revealed "...wound...location...left buttock...wnd [wound] present...on admission no...type...pressure..."

Medical record review of nursing flowsheets dated 3/22/16 through 3/30/16 revealed the patient was turned and repositioned as follows:
3/22/16 twice in a 24 hour period
3/23/16 five times in a 24 hour period
3/26/16 five times in a 24 hour period
3/27/16 nine times in a 24 hour period
3/29/16 four times in a 24 hour period
3/30/16 five times in a 24 hour period

Interview with the Senior Risk Manager on 5/11/16 at 10:35 AM, in the conference room, confirmed the patient was not turned and repositioned every 2 hours and the patient developed a pressure ulcer on his buttocks while he was in the facility.

Interview with the Enterstomal Nurse, on 5/11/16 at 12:38 PM, in the conference room, revealed "...it [pressure ulcer] went from a suspected deep tissue to an unstageable...I ordered the specialty bed...once I knew about it...treatment was started immediately...it was caused by pressure...it could have been prevented...if it's [turning and repositioning] not charted it's not done..." Continued interview confirmed the facility failed to prevent the development of a pressure ulcer.