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RIVENDELL BEHAVIORAL HEALTH SERVICES 1035 PORTER PIKE BOWLING GREEN, KY May 29, 2014
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on record review, interview and review of the facility's policy and procedure it was determine the facility staff failed to report suspected abuse immediately for one (1) of eight (8) patients (Patient #1).

The findings include:

Review of the facility's policy "Investigation and Reporting Allegations of Misconduct, Abuse, Neglect and Exploitation", not dated, revealed patients or any staff may report allegations of staff misconduct to any employee. Staff witnessing, or hearing, or aware of allegations of staff misconduct immediately reports it to the Unit Nurse. The Unit Nurse immediately reports the allegation to the House Supervisor who conducts an initial investigation.

Record review revealed the facility admitted Patient #1 on 04/07/14 with a diagnosis of Episodic Mood Disorder NOS.

Review of a facility investigation revealed an e-mail from the Director of Risk Management to the Assistant Director of Nursing (ADON), Director of Nursing (DON), and others, dated 05/14/14 at 12:34 PM, revealed Registered Nurse (RN) #1 performed unethical holds on Patient #1 and the holds could have been very dangerous for the patient. The e-mail documented the Director of Risk Management had extreme concerns about RN #1 working on the units with patients. Further documentation revealed cameras were reviewed and it was determined RN #1 used an inappropriate hold when trying to transport Patient #1 to the quiet room. RN #1 went and placed Patient #1 in a hold, then it appeared Patient #1 dropped to the ground. At this point RN #1 appeared to grab Patient #1 by the shirt and pull Patient #1 inside the quiet room. RN #1 was immediately suspended pending investigation. Patient #1 at this time has yet to make a complaint; however, actions taken by RN #1 were deemed excessive. On 05/15/14, notification was received that Patient #1 made a complaint that RN #1 pushed his/her head into the floor. This stemmed from the same procedure that was performed incorrectly by RN #1. RN #1 remains suspended as he was removed from patient care after viewing the inappropriate SCM via the camera.

Review of Patient #1's statement, dated 5/15/14 at 2:23 PM, revealed he/she had been up all night talking to RN #1. The patient stated that morning he/she was not following directions so RN #1 had snatched him/her up by his/her shirt with one hand and had the other hand on his/her shoulder and took him/her to the quiet room. He/she revealed RN #1 slammed him/her on the floor and smashed his/her head in the floor with both of his hands. The Patient stated he/she started fighting and other staff came in to hold him/her and RN #1 put his foot on his/her head and Mental Health Associate (MHA) #1 told the RN to stop and the RN stopped.

Review of MHA #1's statement, dated 05/15/14 at 4:00 PM, and interview, on 05/28/14 at 2:15 PM, revealed RN #1 had Patient #1 in a hold and that MHA #2 was on the legs and he was assisting with the arms. MHA #1 stated and documented RN #1 put his knee on Patient #1's head and MHA #1 hit RN #1 on the leg and said "we can't do that". MHA #1 further documented and stated RN #1 removed his knee after he told him "we can't do that", then RN #1 used a hand to push Patient #1's cheek and face into the ground. MHA #1 stated he did not tell anyone until about 12:30 PM. He stated he did not say anything to the oncoming Nurse at that time because RN #1 was still there.

Interview with MHA #2, on 05/28/14 at 2:45 PM, revealed staff should report immediately if they have any knowledge of patient abuse. MHA #2 stated on 05/14/14, staff had Patient #1 in a hold on the floor in the quiet room due to aggressive behavior. MHA #2 revealed the patient was in a supine torso hold with Patient #1 lying on his/her back with arms outstretched and MHA #1 and RN #1 were holding his/her arms. Patient #1 tried to bite RN #1 and RN #1 placed his hand on his/her face and pushed it over to the side. MHA #1 informed RN #1 that was not proper technique and he needed to stop. RN #1 stopped and moved his hand but moved his knee up between the patient's head and shoulder so he/she couldn't bite him. MHA #2 stated MHA #1 again informed RN #1 it was improper. MHA #2 revealed RN #4 then entered the room and suggested we go to a locked door seclusion. MHA #2 stated she reported the incident to her immediate supervisor, the MHA Compliance Supervisor, just before lunch time at 12:30 PM or so. She stated she was going on break, and it was her first time off the floor and away from patients. She stated she did not report the incident to the day shift nurse. MHA #2 revealed the MHA Supervisor said she would take care of it and called the Patient Advocate from the break room. She revealed the facility's policy was for staff to notify the supervisor and she was not sure of the wording of the policy.

Interview with RN #4, on 05/28/14 at 3:05 PM, revealed he came on shift and had to go to the unit Patient #1 was on to get some medications about 7:00 AM. RN #4 stated RN #1 was in the quiet room in a hold with Patient #1 with MHA #1 on the right arm and RN #1 on the left arm. RN #4 further revealed MHA #2 was across the legs and RN #2 across the feet. He stated he stayed to monitor Patient #1 while in the quiet room until RN #1 came back, but RN #1 never came back. He stated he stayed about fifteen (15) minutes and Patient #1 calmed down and he stopped the seclusion. Patient #1 did not complain of pain or injuries but made an allegation that RN #1 slammed his/her head and was holding his/her face during the hold. He stated he told Patient #1 he was going to notify and do what he was supposed to do and told him/her to initiate the grievous process with the Patient Advocate. RN # 4 stated he notified the Patient Advocate five (5) to ten (10) minutes later when he came walking by. RN #4 stated Patient #1 had already called the Patient Advocate. RN #4 stated the DON was on the floor and made aware of the allegation and that the alleged perpetrator was already gone and out of the patient care areas. RN #4 stated the Patient Advocate was already there investigating.

Interview with the Patient Advocate, on 05/28/14 at 3:30 PM, revealed he wasn't working on 05/14/14 and had received a phone call from Patient #1 on 05/15/14 about 9:15 AM when he came back to work, and he/she said a nurse had smashed his/her face into the floor or something along those lines. He stated he went back to the unit and spoke with Patient #1 and he/she said that RN #1 had smashed his/her face into the floor. Patient #1 referenced RN #1 putting his knee on him/her and that MHA #1 and MHA #2 had witnessed it. He stated he then let everyone in Administration know about it. The Patient Advocate revealed he talked with the Risk Manager and RN #1 was already on suspension for improper Safety management Crisis (SMC) holds. He stated he called MHA #1 and got his statement over the phone and then obtained a statement from MHA #2. He revealed a video review was conducted but he was unable to see that area of the quiet room.

Interview with RN #2, on 05/29/14 at 9:15 AM, revealed she worked the morning of 05/14/15 and when she came on the unit there was a procedure going on with Patient #1. RN #2 stated RN #1, MHA #1 and MHA #2 were in the quiet room with Patient #1 supine on the floor on his/her back. RN #2 revealed RN #1 had Patient #1's right arm, MHA #1 had the left arm and MHA #2 had the legs. RN #2 stated RN #1 came out and reported Patient #1 had been up all night had punched him in the head and then proceed to give her report on all the patients, counted medications and left. RN #2 revealed she checked on Patient #1 and asked him/her if in any pain and Patient #1 stated there was no pain but he/she was hungry. RN #2 stated Patient #1 did not make any allegations.

Interview with the MHA Program Director, on 05/29/14 at 10:00 AM, revealed she was working on 05/14/14 and one of her employees (MHA #2) asked her "have you ever had to make a decision between doing the right thing and getting someone in trouble?" and she responded "yes, you do the right thing". The MHA Program Director stated it was around lunch because she was in the break room. She stated MHA #2 told her the hold that happened with Patient #1 that morning was questionable and implied it was a little rough. The MHA Program Director revealed she immediately called the Risk Manager and the Risk Manager pulled up the camera footage with the ADON and they reviewed it. The MHA Program Director stated it was the facility's policy to report alleged abuse immediately and she gave both MHA #1 and #2 written education on the process for reporting. The MHA Program Director stated the MHAs should have reported what they saw immediately to their nurse.

Interview with the Director of Risk Management, on 05/28/14 at 8:30 AM and on 05/29/14 at 12:40 PM, revealed he was first notified on 05/14/14 after the incident around noon after getting a call from the MHA Program Supervisor. He revealed he and the DON reviewed the video and decided RN #1 did not need to be in patient care. He stated he was then notified on 05/15/14 around 10:00 AM to 11:00 AM that Patient #1 had made a complaint to the Patient Advocate. He stated the complaint was investigated and we collected statements and called and reported the allegation. The Director of Risk Management revealed MHA #1 and #2 received education about reporting anything that seemed out of the ordinary immediately.

Interview with the DON, on 05/29/14 at 2:35 PM, revealed staff's failure to report this incident immediately has prompted them to start further education with staff. She stated she talked with MHA #1 and MHA #2, and they didn't report as early as they should have. The DON stated the facility's protocol was for staff to report to the nurse or house supervisor immediately when anything is suspicious. The DON stated the staff should have reported immediately and both have been re-educated.

Interview with the Administrator, on 05/29/14 at 4:00 PM, revealed the alleged abuse was reported to her by the Director of Risk Management on the same day he was notified. She stated she was briefed on the allegation about a procedure and they reviewed the video. She revealed RN #1 was off the floor, as he had worked the night shift and was suspended that day and never returned to patient care. The Administrator stated the MHAs should have reported the incident immediately to the charge nurse per policy.



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