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GEORGIA REGIONAL HOSPITAL ATLANTA 3073 PANTHERSVILLE ROAD DECATUR, GA July 19, 2017
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on review video footage, review of records, policies and procedures, quality data, nursing staffing grid, and staff interview, it was determined that the facility failed to protect the patient's rights and provide care in a safe setting for one (1) patient #8. Specifically, following an attack on the patient by a staff, inaccurate information was documented in the patient's record, the patient was medicated, and law enforcement was not notified.

Cross reference to A0144 as it relates to facility's failure to protect and promote the patient's rights.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review video footage, records, policies and procedures, quality data, nursing staffing grid, and staff interview, it was determined that the facility failed to protect the patient's rights and provide care in a safe setting for Patient #8. Specifically, following an attack on the patient by a staff, appropriate information was not documented in the patient's record, the patient was medicated, and law enforcement was not notified.

Finding included:

A review of the medical record of Patient #8 revealed that the [AGE]-year-old had multiple prior admissions at the facility, including the most recent one on 4/7/17. The patient's diagnoses were; schizoaffective disorder, bipolar type(a mental illness involving delusions, hallucinations and mood problems).
The medical record contained staff documentation that Patient Rights had been provided; staff signed but the patient refused to sign the confirmation of receipt.

Further review of the record revealed that Patient #8 was continuously monitored and observed for aggression and sexually inappropriate behavior on the unit. Record revealed that Patient #8 displayed public masturbation, touching and grabbing peers and staff.
On 7/17/17 at 11:35 a.m., in the risk manager's office the surveyor observed video footage that was captured on 6/2/17 at 7:45 a.m. on the Center unit. The risk manager, assistant risk manager, and business support personnel were present to observe the video. The video revealed that Health Service Technician (HST #1) was in the day area of the Central unit with a blood pressure (B/P) machine nearby and patients were pacing around in the room. HST #1 walked into a room and Patient #8 walked out of the same room. HST #1 walked out of the room, went back to the B/P machine and began to write on a pad which was on a table.

Patient #8 walked over to a chair near the table and rested his/her foot on the chair were HST #1 was standing. HST #1 walked around the table and pushed Patient #8 across the top of a chair; leaned on top of Patient #8 and began striking Patient #8 with his/her right hand. It was not clear from the vantage point of the video, the area of Patient #8's body that was being hit. Support care staff pulled HST #1 away from Patient #8. After the video was observed the Risk Manager confirmed what had been observed and acknowledged that the nurse and facility staff failed to document accurate information in Patient #8's medical record about the events that took place between HST #1 and Patient #8 on 6/2/17.

Review of quality data revealed that the incident between Patient #8 and HST #1 had been classified as A4 (a physically aggressive act to staff). The documentation indicated that Patient #8 tried to enter another individual's room and HST #1 verbally redirected Patient #8. Patient #8 became agitated and walked up to the HST #1 and hit the staff in the face. HST #1 attempted to defend him/herself. Other staff intervened and separated Patient #8 and HST #1.

Registered nurse (RN #4) nurses' notes documented the day after the incident, on 6/3/17 revealed that Patient #8 was on continued observation due to a risk of aggression. At 7:45 a.m. Patient #8 tried to enter another individual's room and HST #1 verbally redirected Patient #8. Patient #8 became agitated and walked up to the HST#1 and hit the HST#1 in the face. HST#1 attempted to defend him/herself and other staff intervened and separated HST #1 and Patient #8. No apparent injury was noted. Patient #8 was given Haldol (a medication for mental disorders) 10 mg and Benadryl 50 mg intramuscularly.

A physician's note dated 6/2/17 revealed that he/she met with and examined Patient #8 at about 9:30 a.m. Patient #8 had old scratches on the face and there was no evidence that Patient #8 had an injury. The patient had attempted to enter another patient's room and was redirected by staff. Patient #8 received Haldol and Benadryl by intramuscular injection and calmed down.

Review of Security Officer #6's report dated 6/2/17, revealed that he/she responded to an incident involving HST #1 and Patient #8 on the Central unit. According to HST #1, he/she was in room #569 taking an individual's vital signs when Patient #8 attempted to enter the room. The Security Officer's report indicated that HST #1 told him/her that HST #1 verbally redirected Patient #1 away from the room, Patient #1 failed to comply and punched the HST #1 in the face with a closed fist. HST #1 attempted to defend him/herself from being injured by Patient #8. The HST #1 reported that other staff intervened and separated Patient #8 from him/her. HST #1 reported that he/she sustained a small cut on his/her right hand.

Patient #8's individual recovery plan documentation dated 6/5/17, revealed that the treatment team met and discussed the 6/2/17 critical incident report that had occurred at 7:45 a.m. According to the record, Patient #8 had been involved in a physically aggressive act to staff after attempts to enter another patient's room. Staff intervened by verbally redirecting Patient #8 several times and Patient #8 hit the staff in the face. Patient #8 was given medication. Recommendations from the physician were to add Depakene (a medication that is used to treat mental disorders) 750 mg twice daily and Zyprexa (used to treat mental disorders) to Patient #8's existing medications.

During an interview at 2:20 p.m. on 7/17/17 in a conference room, Health Service Technician (Employee #2) stated that he/she was in the day area of the Central unit on the morning of 6/2/17 and recalled that Patient #8 was under special observation. HST #1 was the staff person who was responsible for watching Patient #8. Employee #2 stated that Patient #8 went into room #569, which was a different patient's room and HST #1 went into the room to redirect Patient #1. Patient #8 and HST #1 both said something one to the other, and both walked out of the room into the day area. HST #1 was standing at a table and Patient #8 got into HST #1's personal space. Employee #2 stated further that HST #1 was on top of Patient #8 as Patient #8 was leaning on a chair, and both hit each other.

During a telephone interview at 2:48 p.m. on 7/17/17 in a conference room RN #4 stated that on the morning of 6/2/17 he/she was at the nurses' station and heard a commotion and then noticed a fight taking place between two individuals. RN #4 stated that support staff intervened while he/she asked the physician to examine Patient #8 for injuries. RN #4 stated that Patient #8 had no noticeable injuries.

In an interview at 9:30 a.m. on 7/18/17 in a conference room, HST #2 stated that on the morning of 6/2/17 he/she noticed that HST #1 and Patient #8 were arguing loudly, then HST #1 was on top of Patient #8. HST #2 stated that he/she recalled pulling HST #1 off of Patient #8.
In the second interview on 7/18/17 at 2:37 p.m., HST #2 stated "I don't recall HST #1 getting hit in the face by Patient #8.

During an interview at 3:30 p.m. on 7/17/17 in the Central unit group room, Patient #8 stated that he/she recalled an incident/altercation that had occurred between him/herself and HST #1. Patient #8 stated that he/she did not recall who was at fault for the incident. Patient #8 did not respond after being asked to express what he/she recalled about the incident or if he/she had been injured.

During an interview at 11:35 a.m. on 7/18/17 in a conference room, the treatment team facilitator (Employee #5) reviewed Patient #8's record and stated that the treatment team met on 6/5/17 to discuss Patient #8's care. Employee #5 stated that he/she gathers information from other treatment team members in order to formulate the patient's individual recovery plan. Employee #5 stated that he/she had not reviewed the video footage, before documenting in Patient #8's record.

During an interview at 1:52 p.m. on 7/18/17 in a conference room, Security Officer (employee #6) stated that he/she responded to a call to the Central Unit. The RN had told employee #6 that an incident had occurred between HST #1 and Patient #8. The Security Officer stated that he/she met HST #1 near building #1 and obtained a statement. Employee #6 stated that HST #1 told him/her that Patient #8 had punched him/her in the face and HST #1 " lost it " by retaliating. The security officer stated that HST #1 showed his/her thumb which had a less than dime size break in the skin. The security officer further stated that he/she went back to the Central unit and spoke with Patient #8 who explained that he/she did not like HST #1 and that HST #1 had been " messing with him/her ". The security officer stated that he/she did not recall seeing any bruises or signs of injury on Patient #8. Security Officer #6 stated that he/she had not reviewed the video recording of the event that had occurred between HST #1 and Patient #8 prior to writing a report.

A review of the Risk Manager's e-mail documentation on 6/2/17 revealed that the Department of Behavioral Health and Developmental Disabilities; the Department of Human Services; Adult Protective Services and the Georgia Bureau of Investigations had been notified concerning the allegation of physical abuse that HST #1 had inflicted Patient #8. According to the risk manager during the survey closing comments, the Police had not been notified about the incident of patient abuse. The risk manager stated that the incident management policy has documented instructions as to which agencies should be notified following an incident of staff to patient abuse.

Policy #03-515 entitled "Incident Management in Adult Mental Health and Forensic Units" revealed the following, but was not limited to;
Each individual receiving services in Adult Mental Health/Forensics units is entitled to humane care and treatment in a safe setting and is treated with kindness, dignity, and respect.

The Department of Behavioral Health and Developmental Disabilities (BHDD) Adult Mental Health/Forensic Units use an incident management system to identify, report, classify, document, investigate and track incidents of harm or the threat of harm, including incidents involving allegations of Abuse Neglect and Exploitation (ANE)
The policies system includes:
1. Taking immediate steps to protect and comfort any individual(s) involved in the incident;
2. Reporting of the incident to OIMI;
3. Documentation and review of the incident, including using the Executive Leadership Incident Reviews;
4. Notification of other DBHDD employees;
5. Investigation of the incident objectively, timely and thoroughly;
6. Review, implementing and tracking corrective action steps if any are identified;
7. Tracking and trending incidents, including systemic issues; and Reporting as required by State, and Federal law.

Documenting the Incident:
a. Staff completes required Critical Incident Review (CIR) within eight (8) hours of the incident or when the incident is reported to the staff.
b. The CIR includes, at a minimum: an accurate, detailed description of the incident; full names of all individuals, employees, independent contractors and volunteers involved in and witnesses to the incident; who reported the incident, immediate steps taken to prevent re-occurrence and confirm the safety of individuals, employees, independent contractors and volunteers involved, and, as it may apply, known early warning signs or related incidents and appropriate notifications.

RESPONDING TO INCIDENTS:
1. Initial Response and Notifications for all Incidents:
a. All incidents are immediately reported.
b. The staff takes immediate and appropriate actions to protect the rights and safety of all individuals.
c. Staff gives details of the incident immediately to the unit nurse, the senior unit manager, or the charge nurse on duty at the time of the incident, or, if after hours, to the designated Incident Management Officer (IMO), Administrator on Duty (ADO), nurse coordinator (collectively "Supervisor") Supervisor and/or on duty security officer or hospital equivalent.
d. Staff or Supervisor who received the report, notifies infection control, housekeeping, maintenance, pharmacy and/or any other hospital department, as appropriate.
e. Staff or supervisor notifies the physician assigned to the unit or physician on duty if a medical assessment is needed as a result of the incident.

The facility's on-line policy #24-103 entitled "Patient Rights and Client's Rights, last revised 7/23/13 revealed in part:

290-4-9-.03 Treatment or Habilitation Environment-

(c) No staff member shall abuse any client through physical or verbal attack, exploitation,
or coercion.

(d) A staff member who witnesses an incident of such abuse or sexual activity shall report the incident to the Program Director within 24 hours, and to the Program Clients' Rights the staff as specified in the Program's Quality Improvement Plan as soon as possible, which staff shall notify the Personal Advocacy Unit of the Division within 5 working days.

Upon receiving such a report, the Program Clients' Rights Subcommittee shall assist the reporting staff or the client (or his guardian or parent, if applicable) in initiating a complaint pursuant to Section 290-4-9-.04 of these regulations. If the Program Director has reasonable cause to believe that the incident constitutes criminal conduct, he/she/she shall
notify the Regional Executive Director. If the Regional Executive Director agrees, he shall report the incident to the appropriate law enforcement agency.

Review of two (2) weeks staffing (5/28/4/201 7 to 6/3/2017, 6/4/2017 to 6/10/2017 for the Central unit, revealed that staffing was adequate per the facility's staffing matrix/grid.

Review of personnel files # (1, 2, 3 and 4) revealed that all contained initial applications and job descriptions; all had undergone criminal history record checks prior to being hired; had the required orientation; had current competency testing and evaluations and had annual safety care training. Employee #1 had submitted a letter of resignation on 6/5/17 which was acknowledged by the facility's Human Resource Department.