The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

OAKBEND MEDICAL CENTER 1705 JACKSON ST RICHMOND, TX 77469 April 24, 2014
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on interview and record review, the hospital failed to protect the rights of two of two patients that alleged abuse by facility staff. (Patient ID#' s 1 and 11)

Findings include:

1. The hospital failed to investigate and resolve timely the allegations of abuse by staff on 2 of 2 patients (Patient ID# 1 and Patient ID # 11). Refer to Tag A118.

2. The hospital failed to ensure that patients received care in a safe setting for 2 of 2 patients (Patient ID# 1 and Patient ID # 11). Refer to Tag 144.

3. The hospital failed to ensure that patients are free from abuse and harassment for 2 of 2 patients (Patient ID# 1 and Patient ID # 11). Refer to Tag 145.
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



Based on interview and record review the hospital failed to ensure prompt resolution of patient grievance in 2 of 2 patient grievances alleging abuse from staff. (Patient ID# 1 and #11)

Findings include:

During the entrance conference at the Hospital 4/23/14, at 9 a.m., for a complaint investigation the Administrator (ID# 50) informed the surveyor that the hospital did not have any knowledge (no incident reports) of alleged patient abuse that occurred at the hospital. The Administrator stated that the Nursing Supervisor on duty after hours was responsible for administrative and technical supervision of all personal during designated times when hospital management team is not in the hospital. The Administrator further stated that all alleged patient abuse allegations should have had an incident report generated for proper communication per policy.

PATIENT ID# 1

Review of the medical record of Patient ID# 1 revealed that the patient was a 33 year old, male, who was brought to the emergency room of the hospital by emergency medical services (ambulance) on 4/4/14 at 21:56 PM. The narrative stated "Found on street unresponsive with history of heroin addiction and pinpoint pupils. Narcan 2 mg given by EMS and patient woke up and became combative. Patient is suicidal per police with B-B gun beside him on road. Responds appropriately to painful stimuli on ER arrival." A physician medical screen stated "Altered Mental State, Drug Abuse, and Suicidal Intent." A urine drug screen on 4/4/14, tested positive for Benzodiazepines, Opiates, Cocaine, and Methadone.

A physician order dated 4/4/14, at 22:03 PM showed "Continuous Monitoring due to Suicidal Intent." A Security Guard was assigned to constantly sit with the patient.

Patient ID# 1 was kept in the emergency room from 4/4/14 to 4/5/14 until his medical condition stabilized.

Another physician order dated 4/5/14, at 6:13 a.m., showed "Call (Contract Psychiatric Counselor to evaluate patient). Continue continuous observation."

Telephone interview on 4/22/14, at 9:30 a.m., with Security Guard ID# 65 revealed that he was assigned to sit with Patient ID# 1 in the emergency room on [DATE]. The Security Guard stated that he had only worked at the hospital for a couple of months. The Security Guard stated that on 4/5/14, around 15:00 PM, a psychiatric counselor (ID# 64) entered Patient ID# 1's room to evaluate the patient for placement but could not get the patient to wake up. The patient was unresponsive, so the counselor stated that she would come back the following day for the evaluation.

Security Guard ID# 65 stated that once the emergency room charge nurse (ID# 57 ) found out that the counselor was leaving, she told the counselor to wait. The Security Guard stated that the Counselor was in the "vicinity" of the patient's room but not inside the patient's room at that time. Then, the Security Guard stated that charge nurse ID# 57 went into Patient ID#1's room making a comment that "she was going to make the patient as uncomfortable as possible so he would not want to stay here" and proceeded to kick the patient's foot that was hanging off the stretcher trying to wake the patient up. The patient immediately woke up screaming in pain asking "Why did you do that; that hurts?" An argument ensued between the charge nurse and the patient, and the patient began cursing at the nurse. The nurse continued to provoke the patient by saying the patient was going to jail if he did not cooperate.

The Security Guard ID# 65 stated he immediately notified his supervisor (ID# 53) that nurse ID# 57 kicked the foot of patient ID# 1 trying to wake him up. The Security Guard stated that he called his Supervisor a second time to report that the patient wanted to press charges against nurse ID# 57. The Security Guard stated that his supervisor removed him from sitting with patient ID# 1 and assigned another Security Guard to watch over Patient ID# 1.

Interview on 4/23/14, at 9:45 a.m., with the Director of Security (ID# 53) revealed: The Director of Security stated that his security guard (ID# 65) called him on 4/5/14, and said a nurse kicked a patient. The Director of Security stated that he notified the House Nursing Supervisor (ID# 60) of the allegation but did not complete an incident report.

Telephone interview on 4/23/14, at 11:10 a.m., with the Nursing Supervisor (ID# 60) revealed: The Nursing Supervisor remembered receiving a call from the Director of Security on 4/5/14, and asked her if she could go down to the emergency room and see what was going on. A security Guard (ID# 65) had alleged that Nurse ID# 57 kicked Patient ID# 1. The Nursing Supervisor went to the emergency room and spoke with Nurse ID# 57, the charge nurse of the emergency room . Nurse ID# 57 proceeded to explain to the Supervisor that Patient ID# 1 had been in the emergency room all day. A contract psychiatric counselor came to evaluate the patient but the patient had dozed off to sleep and the counselor said she would come back later. Nurse ID# 57 told the Supervisor that she tapped the patient on the foot to wake him up. The Nursing Supervisor stated that Nurse ID# 57 denied kicking the patient.

The Nursing Supervisor informed the surveyor that she did not interview the Security Guard sitting with Patient ID# 1 because she felt that was the job of the Security Guard's supervisor. The Nursing Supervisor further stated that she did not make an incident report or interview any other nurses in the emergency room regarding the alleged abuse. She only interviewed Nurse ID# 57.

During the interview with Nurse ID# 57 on 4/23/14, at 3 p.m., she informed the surveyor that patient ID# 1 was a psychiatric patient in the ER on 4/5/14. The patient had been held in the emergency department for over 24 hours pending a psychiatric evaluation. A psychiatric counselor (ID# 64) came to evaluate the patient. The counselor came to see the patient and then the charge nurse noticed the counselor walking out the door with her purse. The Charge Nurse (ID# 57) immediately stopped the counselor and asked her why she was leaving without evaluating the patient for placement. The counselor told her that the patient will not wake up for the evaluation to be done. The Charge Nurse told the counselor that the patient had been awake previously and to hold on. The Charge Nurse stated she entered patient ID# 1's room and the patient was "out of it." The Charge Nurse stated she proceeded to "tap" the patient on the foot to wake him up and told him that he needed to wake up and talk to the counselor. The patient became upset and began cursing. The Charge Nurse said she then told the patient that if he did not cooperate with the counselor he would go to jail. The patient became very belligerent and cursing. The patient eventually calmed down enough for the counselor to do a psychiatric evaluation.

The Charge Nurse (ID# 57) denied kicking patient ID# 1. The Charge Nurse admitted she may have startled the patient when she tapped him on the foot to wake him up. The Charge Nurse stated she did not complete an incident report after the patient accused her of kicking him.

The telephone interview on 4/22/14, at 11 a.m., with a contract psychiatric counselor (ID# 64) revealed that she was called on 4/5/14, to Oak Bend Medical Center to evaluate a psychiatric patient (ID# 1). The counselor stated that when she arrived at the emergency room , the patient remained unresponsive so she told the staff she would have to come back the next day to evaluate the patient. After she left the patient's room she heard the patient call out "You can't kick me, you can't do that!" The counselor stated that Nurse ID# 57 and the Security Guard (ID# 65) were the only staff in the room at the time the patient made those comments.


PATIENT ID# 11

Review of the medical record for patient ID# 11 dated 2/18/14 to 3/12/14 revealed this was a 73-year old, female, admitted to the geripsych unit with a diagnosis of "Schizophrenia, Chronic Paranoid., and Psychosis." An initial Master Treatment plan dated 2/18/14, identified the following problems: Agitation, Verbal aggression, anxiety, impulsivity, and mood swings. On 2/20/14, the Treatment Plan expanded to include "Paranoid ideation's." The discharge summary stated "This is a [AGE]-year-old female brought to the ER from her nursing home due to aggression and agitation with paranoid ideation, admitted to the geripsych unit."

Telephone interview on 4/22/14, at 9:30 a.m., with Security Guard (ID# 65) stated that he was making rounds (unknown exact date) on the Geriatric Psychiatric Unit and Patient ID# 11 told him she had been assaulted by a nurse aide. The Security Guard reported it to the Nursing House Supervisor (ID# 60).

Telephone interview with the Nursing Supervisor (ID# 60) 4/24/14, at 2:10 p.m., revealed that Security Guard ID# 65 reported to her that he was making rounds on the geriatric psychiatric unit and a Patient (ID# 11) reported to him that someone pinned her down in her room and was hitting her. The Nursing Supervisor stated she interviewed the nurse on duty of the unit and was told the patient tells these stories all the time. When the patient was questioned the patient stated the Security Guard had touched her inappropriately. The Nursing Supervisor stated she did not complete an incident report.

Review of policy titled "Patient Bill of Rights" dated 3/14 stated: "Patient Rights: As a patient at Oakbend Medical Center you have the right:
1) To considerate, respectful care at all times.
17) To receive care in safe setting.


Record review of a job description titled "Nursing Administration Administrative Supervisor" stated "The Administrative Supervisor assumes the responsibility for the administrative and technical supervision of all personnel during designated times when hospital management team is not in the hospital ....Job Specific Standards: 9. Documents shift activity in reports daily to administration and directors as appropriate ..... 11. Investigates and follows-up on medication errors, incident reports and patient complaints with appropriate documentation and corrective action as necessary ...15. Ensure Administrator is informed...18) Compliance: Understands and complies with all hospital department and environment of care policies and procedures ..."

Record review of a job description titled "Emergency Care Center - Charge Nurse" stated "Job Specific Standards: 5. Investigates and follow-up on medication errors, incident reports and patient complaints with appropriate follow-up documentation and corrective action as determined by the Unit Director ..."

The Nursing Supervisor failed to investigate the incidents of alleged abuse by staff on patients. Further, the Nursing Supervisor failed to document the alleged abuse and failed to inform the Administrator as required by the hospital policy.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



Based on interview and record review the hospital failed ensure 2 of 2 patients (Patient ID# 1 and Patient ID# 11) received care in a safe setting in that there were no appropriate actions taken regarding two allegations of abuse of patients by staff. This failure could affect all patients admitted to this hospital will potentially be exposed to abuse by staff.

Findings include:

During the entrance conference at the Hospital 4/23/14, at 9 a.m., for a complaint investigation the Administrator (ID# 50) informed the surveyor that the hospital did not have any knowledge (no incident reports) of alleged patient abuse that occurred at the hospital. The Administrator stated that the Nursing Supervisor on duty after hours was responsible for administrative and technical supervision of all personal during designated times when hospital management team is not in the hospital. The Administrator further stated that all alleged patient abuse allegations should have had an incident report generated for proper communication per policy.

PATIENT ID# 1

Review of the medical record of Patient ID# 1 revealed that the patient was a 33 year old, male, who was brought to the emergency room of the hospital by emergency medical services (ambulance) on 4/4/14 at 21:56 PM. The narrative stated "Found on street unresponsive with history of heroin addiction and pinpoint pupils. Narcan 2 mg given by EMS and patient woke up and became combative. Patient is suicidal per police with B-B gun beside him on road. Responds appropriately to painful stimuli on ER arrival." A physician medical screen stated "Altered Mental State, Drug Abuse, and Suicidal Intent." A urine drug screen on 4/4/14, tested positive for Benzodiazepines, Opiates, Cocaine, and Methadone.

A physician order dated 4/4/14, at 22:03 PM showed "Continuous Monitoring due to Suicidal Intent." A Security Guard was assigned to constantly sit with the patient.

Patient ID# 1 was kept in the emergency room from 4/4/14 to 4/5/14 until his medical condition stabilized.

Another physician order dated 4/5/14, at 6:13 a.m., showed "Call (Contract Psychiatric Counselor to evaluate patient). Continue continuous observation."

Telephone interview on 4/22/14, at 9:30 a.m., with Security Guard ID# 65 revealed that he was assigned to sit with Patient ID# 1 in the emergency room on [DATE]. The Security Guard stated that he had only worked at the hospital for a couple of months. The Security Guard stated that on 4/5/14, around 15:00 PM, a psychiatric counselor (ID# 64) entered Patient ID# 1's room to evaluate the patient for placement but could not get the patient to wake up. The patient was unresponsive, so the counselor stated that she would come back the following day for the evaluation.

Security Guard ID# 65 stated that once the emergency room charge nurse (ID# 57 ) found out that the counselor was leaving, she told the counselor to wait. The Security Guard stated that the Counselor was in the "vicinity" of the patient's room but not inside the patient's room at that time. Then, the Security Guard stated that charge nurse ID# 57 went into Patient ID#1's room making a comment that "she was going to make the patient as uncomfortable as possible so he would not want to stay here" and proceeded to kick the patient's foot that was hanging off the stretcher trying to wake the patient up. The patient immediately woke up screaming in pain asking "Why did you do that; that hurts?" An argument ensued between the charge nurse and the patient, and the patient began cursing at the nurse. The nurse continued to provoke the patient by saying the patient was going to jail if he did not cooperate.

The Security Guard ID# 65 stated he immediately notified his supervisor (ID# 53) that nurse ID# 57 kicked the foot of patient ID# 1 trying to wake him up. The Security Guard stated that he called his Supervisor a second time to report that the patient wanted to press charges against nurse ID# 57. The Security Guard stated that his supervisor removed him from sitting with patient ID# 1 and assigned another Security Guard to watch over Patient ID# 1.

Interview on 4/23/14, at 9:45 a.m., with the Director of Security (ID# 53) revealed: The Director of Security stated that his security guard (ID# 65) called him on 4/5/14, and said a nurse kicked a patient. The Director of Security stated that he notified the House Nursing Supervisor (ID# 60) of the allegation but did not complete an incident report.

Telephone interview on 4/23/14, at 11:10 a.m., with the Nursing Supervisor (ID# 60) revealed: The Nursing Supervisor remembered receiving a call from the Director of Security on 4/5/14, and asked her if she could go down to the emergency room and see what was going on. A security Guard (ID# 65) had alleged that Nurse ID# 57 kicked Patient ID# 1. The Nursing Supervisor went to the emergency room and spoke with Nurse ID# 57, the charge nurse of the emergency room . Nurse ID# 57 proceeded to explain to the Supervisor that Patient ID# 1 had been in the emergency room all day. A contract psychiatric counselor came to evaluate the patient but the patient had dozed off to sleep and the counselor said she would come back later. Nurse ID# 57 told the Supervisor that she tapped the patient on the foot to wake him up. The Nursing Supervisor stated that Nurse ID# 57 denied kicking the patient.

The Nursing Supervisor informed the surveyor that she did not interview the Security Guard sitting with Patient ID# 1 because she felt that was the job of the Security Guard's supervisor. The Nursing Supervisor further stated that she did not make an incident report or interview any other nurses in the emergency room regarding the alleged abuse. She only interviewed Nurse ID# 57.

During the interview with Nurse ID# 57 on 4/23/14, at 3 p.m., she informed the surveyor that patient ID# 1 was a psychiatric patient in the ER on 4/5/14. The patient had been held in the emergency department for over 24 hours pending a psychiatric evaluation. A psychiatric counselor (ID# 64) came to evaluate the patient. The counselor came to see the patient and then the charge nurse noticed the counselor walking out the door with her purse. The Charge Nurse (ID# 57) immediately stopped the counselor and asked her why she was leaving without evaluating the patient for placement. The counselor told her that the patient will not wake up for the evaluation to be done. The Charge Nurse told the counselor that the patient had been awake previously and to hold on. The Charge Nurse stated she entered patient ID# 1's room and the patient was "out of it." The Charge Nurse stated she proceeded to "tap" the patient on the foot to wake him up and told him that he needed to wake up and talk to the counselor. The patient became upset and began cursing. The Charge Nurse said she then told the patient that if he did not cooperate with the counselor he would go to jail. The patient became very belligerent and cursing. The patient eventually calmed down enough for the counselor to do a psychiatric evaluation.

The Charge Nurse (ID# 57) denied kicking patient ID# 1. The Charge Nurse admitted she may have startled the patient when she tapped him on the foot to wake him up. The Charge Nurse stated she did not complete an incident report after the patient accused her of kicking him.

The telephone interview on 4/22/14, at 11 a.m., with a contract psychiatric counselor (ID# 64) revealed that she was called on 4/5/14, to Oak Bend Medical Center to evaluate a psychiatric patient (ID# 1). The counselor stated that when she arrived at the emergency room , the patient remained unresponsive so she told the staff she would have to come back the next day to evaluate the patient. After she left the patient's room she heard the patient call out "You can't kick me, you can't do that!" The counselor stated that Nurse ID# 57 and the Security Guard (ID# 65) were the only staff in the room at the time the patient made those comments.


PATIENT ID# 11

Review of the medical record for patient ID# 11 dated 2/18/14 to 3/12/14 revealed this was a 73-year old, female, admitted to the geripsych unit with a diagnosis of "Schizophrenia, Chronic Paranoid., and Psychosis." An initial Master Treatment plan dated 2/18/14, identified the following problems: Agitation, Verbal aggression, anxiety, impulsivity, and mood swings. On 2/20/14, the Treatment Plan expanded to include "Paranoid ideation's." The discharge summary stated "This is a [AGE]-year-old female brought to the ER from her nursing home due to aggression and agitation with paranoid ideation, admitted to the geripsych unit."

Telephone interview on 4/22/14, at 9:30 a.m., with Security Guard (ID# 65) stated that he was making rounds (unknown exact date) on the Geriatric Psychiatric Unit and Patient ID# 11 told him she had been assaulted by a nurse aide. The Security Guard reported it to the Nursing House Supervisor (ID# 60).

Telephone interview with the Nursing Supervisor (ID# 60) 4/24/14, at 2:10 p.m., revealed that Security Guard ID# 65 reported to her that he was making rounds on the geriatric psychiatric unit and a Patient (ID# 11) reported to him that someone pinned her down in her room and was hitting her. The Nursing Supervisor stated she interviewed the nurse on duty of the unit and was told the patient tells these stories all the time. When the patient was questioned the patient stated the Security Guard had touched her inappropriately. The Nursing Supervisor stated she did not complete an incident report.

Review of policy titled "Patient Bill of Rights" dated 3/14 stated: "Patient Rights: As a patient at Oakbend Medical Center you have the right:
1) To considerate, respectful care at all times.
17) To receive care in safe setting.
18) To be free from abuse and harassment.

Record review of a job description titled "Nursing Administration Administrative Supervisor" stated "The Administrative Supervisor assumes the responsibility for the administrative and technical supervision of all personnel during designated times when hospital management team is not in the hospital ....Job Specific Standards: 9. Documents shift activity in reports daily to administration and directors as appropriate ..... 11. Investigates and follows-up on medication errors, incident reports and patient complaints with appropriate documentation and corrective action as necessary ...15. Ensure Administrator is informed...18) Compliance: Understands and complies with all hospital department and environment of care policies and procedures ..."

Record review of a job description titled "Emergency Care Center - Charge Nurse" stated "Job Specific Standards: 5. Investigates and follow-up on medication errors, incident reports and patient complaints with appropriate follow-up documentation and corrective action as determined by the Unit Director ..."

The staff that abused Patient ID# 1 remained on staff at the time of the survey. The hospital have not implemented measures to ensure that patients will be free of abuse from staff at the time of the survey.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



Based on interview and record review the hospital failed to ensure 2 of 2 patients were free from alleged abuse. (Patient ID# 1 and Patient ID# 11)

Findings include:

During the entrance conference at the Hospital 4/23/14, at 9 a.m., for a complaint investigation the Administrator (ID# 50) informed the surveyor that the hospital did not have any knowledge (no incident reports) of alleged patient abuse that occurred at the hospital. The Administrator stated that the Nursing Supervisor on duty after hours was responsible for administrative and technical supervision of all personal during designated times when hospital management team is not in the hospital. The Administrator further stated that all alleged patient abuse allegations should have had an incident report generated for proper communication per policy.

PATIENT ID# 1

Review of the medical record of Patient ID# 1 revealed that the patient was a 33 year old, male, who was brought to the emergency room of the hospital by emergency medical services (ambulance) on 4/4/14 at 21:56 PM. The narrative stated "Found on street unresponsive with history of heroin addiction and pinpoint pupils. Narcan 2 mg given by EMS and patient woke up and became combative. Patient is suicidal per police with B-B gun beside him on road. Responds appropriately to painful stimuli on ER arrival." A physician medical screen stated "Altered Mental State, Drug Abuse, and Suicidal Intent." A urine drug screen on 4/4/14, tested positive for Benzodiazepines, Opiates, Cocaine, and Methadone.

A physician order dated 4/4/14, at 22:03 PM showed "Continuous Monitoring due to Suicidal Intent." A Security Guard was assigned to constantly sit with the patient.

Patient ID# 1 was kept in the emergency room from 4/4/14 to 4/5/14 until his medical condition stabilized.

Another physician order dated 4/5/14, at 6:13 a.m., showed "Call (Contract Psychiatric Counselor to evaluate patient). Continue continuous observation."

Review of Nursing Notes for Patient ID# 1 dated 4/5/14 were as follows:

8:12 a.m. "Patient resting in bed with eyes closed, patient is easily arousable but still lethargic ...security guard sitting at bedside monitoring patient for safety, patient unable to carry on a conversation at this time noted ..."

10:00 a.m. "Patient sitting up in bed, awake, alert and oriented X 4, denies having any suicidal or homicidal thoughts or ideations at this time, patient reports he has no memory of last night but denies wanting to harm or kill himself ...Screener (Counselor) notified that patient is now awake and alert and cooperative with care at this time, will be coming out to evaluate patient noted."

1:00 p.m. "Patient resting in bed, no complaints voiced, security guard sitting in patients doorway for continuous monitoring for patients safety ..."

4:00 p.m. "Patient is sitting up in the bed, awake, eating evening meal tray. No complaints voiced."

4:20 p.m. "Patient notified that he will be going to a Crisis Center and he became very upset and started yelling at staff and the Registered Nurse (RN) and making verbal threats to harm the staff and tear up the ER room if he does not get released ..."

4:29 p.m. "After the counselor explained the situation to the patient the patient has calmed down and agreed to stay here in the ER until able to be transferred to the Crisis Center ..."

5:13 p.m. "Patients hands and arms shaking and patient is becoming increasingly anxious and requested something to help calm him down, Dr. notified and new orders received. (Patient was given injection of Ativan 2mg at 5:29 p.m.)"

6:55 p.m. "Counselor called and informed RN that patient is clear to go to the Crisis Center at this time. County Sheriff office consulted to transport patient.." (The patient was discharged from the emergency room at 7:35 p.m. and vital signs were stable)

Telephone interview on 4/22/14, at 9:30 a.m., with Security Guard ID# 65 revealed that he was assigned to sit with Patient ID# 1 in the emergency room on [DATE]. The Security Guard stated that he had only worked at the hospital for a couple of months. The Security Guard stated that on 4/5/14, around 15:00 PM, a psychiatric counselor (ID# 64) entered Patient ID# 1's room to evaluate the patient for placement but could not get the patient to wake up. The patient was unresponsive, so the counselor stated that she would come back the following day for the evaluation.

Security Guard ID# 65 stated that once the emergency room charge nurse (ID# 57 ) found out that the counselor was leaving, she told the counselor to wait. The Security Guard stated that the Counselor was in the "vicinity" of the patient's room but not inside the patient's room at that time. Then, the Security Guard stated that charge nurse ID# 57 went into Patient ID#1's room making a comment that "she was going to make the patient as uncomfortable as possible so he would not want to stay here" and proceeded to kick the patient's foot that was hanging off the stretcher trying to wake the patient up. The patient immediately woke up screaming in pain asking "Why did you do that; that hurts?" An argument ensued between the charge nurse and the patient, and the patient began cursing at the nurse. The nurse continued to provoke the patient by saying the patient was going to jail if he did not cooperate.

The Security Guard ID# 65 stated he immediately notified his supervisor (ID# 53) that nurse ID# 57 kicked the foot of patient ID# 1 trying to wake him up. The Security Guard stated that he called his Supervisor a second time to report that the patient wanted to press charges against nurse ID# 57. The Security Guard stated that his supervisor removed him from sitting with patient ID# 1 and assigned another Security Guard to watch over Patient ID# 1.

Interview on 4/23/14, at 9:45 a.m., with the Director of Security (ID# 53) revealed: The Director of Security stated that his security guard (ID# 65) called him on 4/5/14, and said a nurse kicked a patient. The Director of Security stated that he notified the House Nursing Supervisor (ID# 60) of the allegation but did not complete an incident report.

Telephone interview on 4/23/14, at 11:10 a.m., with the Nursing Supervisor (ID# 60) revealed: The Nursing Supervisor remembered receiving a call from the Director of Security on 4/5/14, and asked her if she could go down to the emergency room and see what was going on. A security Guard (ID# 65) had alleged that Nurse ID# 57 kicked Patient ID# 1. The Nursing Supervisor went to the emergency room and spoke with Nurse ID# 57, the charge nurse of the emergency room . Nurse ID# 57 proceeded to explain to the Supervisor that Patient ID# 1 had been in the emergency room all day. A contract psychiatric counselor came to evaluate the patient but the patient had dozed off to sleep and the counselor said she would come back later. Nurse ID# 57 told the Supervisor that she tapped the patient on the foot to wake him up. The Nursing Supervisor stated that Nurse ID# 57 denied kicking the patient.

The Nursing Supervisor informed the surveyor that she did not interview the Security Guard sitting with Patient ID# 1 because she felt that was the job of the Security Guard's supervisor. The Nursing Supervisor further stated that she did not make an incident report or interview any other nurses in the emergency room regarding the alleged abuse. She only interviewed Nurse ID# 57.

During the interview with Nurse ID# 57 on 4/23/14, at 3 p.m., she informed the surveyor that patient ID# 1 was a psychiatric patient in the ER on 4/5/14. The patient had been held in the emergency department for over 24 hours pending a psychiatric evaluation. A psychiatric counselor (ID# 64) came to evaluate the patient. The counselor came to see the patient and then the charge nurse noticed the counselor walking out the door with her purse. The Charge Nurse (ID# 57) immediately stopped the counselor and asked her why she was leaving without evaluating the patient for placement. The counselor told her that the patient will not wake up for the evaluation to be done. The Charge Nurse told the counselor that the patient had been awake previously and to hold on. The Charge Nurse stated she entered patient ID# 1's room and the patient was "out of it." The Charge Nurse stated she proceeded to "tap" the patient on the foot to wake him up and told him that he needed to wake up and talk to the counselor. The patient became upset and began cursing. The Charge Nurse said she then told the patient that if he did not cooperate with the counselor he would go to jail. The patient became very belligerent and cursing. The patient eventually calmed down enough for the counselor to do a psychiatric evaluation.

The Charge Nurse (ID# 57) denied kicking patient ID# 1. The Charge Nurse admitted she may have startled the patient when she tapped him on the foot to wake him up. The Charge Nurse stated she did not complete an incident report after the patient accused her of kicking him.

The telephone interview on 4/22/14, at 11 a.m., with a contract psychiatric counselor (ID# 64) revealed that she was called on 4/5/14, to Oak Bend Medical Center to evaluate a psychiatric patient (ID# 1). The counselor stated that when she arrived at the emergency room , the patient remained unresponsive so she told the staff she would have to come back the next day to evaluate the patient. After she left the patient's room she heard the patient call out "You can't kick me, you can't do that!" The counselor stated that Nurse ID# 57 and the Security Guard (ID# 65) were the only staff in the room at the time the patient made those comments.


PATIENT ID# 11

Review of the medical record for patient ID# 11 dated 2/18/14 to 3/12/14 revealed this was a 73-year old, female, admitted to the geripsych unit with a diagnosis of "Schizophrenia, Chronic Paranoid., and Psychosis." An initial Master Treatment plan dated 2/18/14, identified the following problems: Agitation, Verbal aggression, anxiety, impulsivity, and mood swings. On 2/20/14, the Treatment Plan expanded to include "Paranoid ideation's." The discharge summary stated "This is a [AGE]-year-old female brought to the ER from her nursing home due to aggression and agitation with paranoid ideation, admitted to the geripsych unit."

Telephone interview on 4/22/14, at 9:30 a.m., with Security Guard (ID# 65) stated that he was making rounds (unknown exact date) on the Geriatric Psychiatric Unit and Patient ID# 11 told him she had been assaulted by a nurse aide. The Security Guard reported it to the Nursing House Supervisor (ID# 60).

Telephone interview with the Nursing Supervisor (ID# 60) 4/24/14, at 2:10 p.m., revealed that Security Guard ID# 65 reported to her that he was making rounds on the geriatric psychiatric unit and a Patient (ID# 11) reported to him that someone pinned her down in her room and was hitting her. The Nursing Supervisor stated she interviewed the nurse on duty of the unit and was told the patient tells these stories all the time. When the patient was questioned the patient stated the Security Guard had touched her inappropriately. The Nursing Supervisor stated she did not complete an incident report.

Review of policy titled "Patient Bill of Rights" dated 3/14 stated: "Patient Rights: As a patient at Oakbend Medical Center you have the right:
1) To considerate, respectful care at all times.
17) To receive care in safe setting.
18) To be free from abuse and harassment.

Record review of a job description titled "Nursing Administration Administrative Supervisor" stated "The Administrative Supervisor assumes the responsibility for the administrative and technical supervision of all personnel during designated times when hospital management team is not in the hospital ....Job Specific Standards: 9. Documents shift activity in reports daily to administration and directors as appropriate ..... 11. Investigates and follows-up on medication errors, incident reports and patient complaints with appropriate documentation and corrective action as necessary ...15. Ensure Administrator is informed...18) Compliance: Understands and complies with all hospital department and environment of care policies and procedures ..."

Record review of a job description titled "Emergency Care Center - Charge Nurse" stated "Job Specific Standards: 5. Investigates and follow-up on medication errors, incident reports and patient complaints with appropriate follow-up documentation and corrective action as determined by the Unit Director ..."

The hospital failed to take action or implement corrective measures at the time of the survey to ensure that patients will not be subjected to any form of abuse or harrassment from staff.