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Intakes: TN 476

Based on facility policy, document review, medical record review and interview, the facility failed to follow written policies and protocols to identify, report and investigate all types of abuse for 1 of 1 (Patient #3) sampled patients who was injured during a resident to resident assault.

The findings included:

1. The facility failed to failed to follow policies for identifying, reporting and investigating abuse and failed to implement measures to protect residents from future occurrences in a timely manner.

Refer to A 145

Based on facility policy, document review, medical record review, and interview, the facility failed to protect vulnerable patients from all forms of abuse for 1 of 1 (Patient #3) sampled patient who sustained a serious head injury during a patient to patient assault. The facility failed to investigate and report according to their investigation policy and failed to implement measures to prevent incidents of this type from occurring again. Additionally the hospital failed to respond with appropriate interventions to ensure patients were safe from abuse.

The findings included:

1. Review of the facility's Investigation Policy revealed, "Purpose: This policy establishes guidelines for investigating allegations, complaints, or evidence of abuse, neglect, mistreatment or misappropriation of the property of persons served by the [Name of Regional Facility] in order to increase the safety of the service recipients at the [Name of Regional Facility]...Policy: Any allegation or complaint related to the actions of the Facility Investigator shall be reported directly to the Director of the Office of Licensure and Review(OLR)...Abuse: Knowingly threatening to touch, attempting to touch, or actually touching a service recipient in any manner which a reasonable person would recognize as likely to be harmful or painful or to cause mental anguish... Knowingly inflicting injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish...Neglect: Failure to provide goods or services necessary to avoid physical harm, mental anguish, or mental illness, which results in injury or probable risk of serious harm to a service recipient...Procedures:...Receiving all allegations, complaints, or evidence of abuse, neglect, mistreatment or misappropriation of the property of persons served by the [Name of Regional Facility]...Gathering preliminary information to determine if a full investigation is warranted, including, but not limited to, reviewing surveillance tapes, conducting interviews, and reviewing documents as indicated;...Investigating all suspicious injuries to determine, if possible, whether abuse, neglect, or mistreatment has occurred and, if so, treating the injury as an allegation or evidence of abuse, neglect, or mistreatment;...Investigating fully all allegations, complaints, or evidence of abuse, neglect, mistreatment or misappropriation of a service recipient's property;...Referring case to [Name of Regional Facility] Chief Officer for a determination of whether to substantiate a case of abuse, neglect, mistreatment or misappropriation of a service recipient's property...Remaining independent and objective with respect to service recipient treatment and routine facility operations and functions, and...Assuring that appropriate chain of evidence procedures are followed at all times;...Adhering to the following standards or timelines regarding investigations:Initiate an investigation within twenty-four (24) hours of receipt of the allegation, complaint or knowledge of the incident; Notify Chief Officer or designee immediately (but no more than one (1) hour) upon the Investigator's receiving notice of an allegation, complaint or evidence of abuse, neglect, or mistreatment involving death or an injury classified as serious or severe...Forwarding a copy of the Initial Investigative Report to the Director of OLR within twenty-four (24) hours of notice to the Investigator...Completing a full investigation, when indicated, within fifteen (15) business days of receipt of the allegation, complaint or knowledge of the incident..."

Review of the facility's Incident Reporting Policy revealed, "Purpose: To delineate the responsibilities of [Name of State Department and Name of Regional Facilities] in identifying, reporting, managing, and resolving incidents in order to increase the safety of the patients at the [Name of Regional Facilities]...Policy: All incidents involving [Name of Regional Facility] patients, including incidents that are reported by patients but not directly observed by a employee, must be reported. This includes incidents that occur during hospitalization , but not reported until after the patient is discharged ..."Definitions: Physical Abuse: Harmful or painful physical contact, including, but not limited to,the intentional striking, shoving, or pushing of a patient by anyone, including another patient...Incident: Any event that results in harm or significant risk of harm to a patient or any even involving a patient that results in harm or a significant risk of harm to another person or property..."

Review of the facility's "Root Cause Analysis (RCA)" dated 4/6/16 revealed, "The RCA focus on a specific incident which occurred on March 10, 2016 involving [Patient #3] and a male peer [Patient #5]. Per our documentation, [Patient #3] 'cursed out' a male peer [Patient #5], the male peer then struck [Patient #3] in the face. [Patient #3] briefly lost consciousness after being a result of the identification of.. two possible proximate causes of this incident, the RCA team recommended the following corrective action: 1. The 'Patient Orientation to Unit' form will be revised to formally introduce patients to new roommates. Staff will also be required to assess and document the interaction between the patients on the 'Orientation to Unit' form. Additionally, the 'Admissions /Unit Admission' policy will be revised to reflect these new requirements and expectations. 2. In the future, every effort will be made to obtain all available prior medical records as soon as possible. The treatment team and attending physicians will be made aware of the availability of these records..."

2. Record review for Patient #3 (Patient Named in Complaint) revealed the date of birth (DOB) as 8/12/1946. Patient #3 was admitted on [DATE] and discharged on [DATE]. The patient was on Medical Leave of Absence beginning 3/10/16. Admitting diagnosis included; Schizoaffective Disorder (D/O), Antisocial Personality D/O, Hypertension (HTN) and Parkinsonism. The "Justification for Admission" was documented as; "The patient is psychotic and a danger to other, brought in by [Name of Police Department] due to threatening and dangerous behavior of smearing feces on the walls, yelling at others, and threatening to spit on others. At [Name of Transferring Facility], he was lying on the floor, refusing to answer questions. He is agitated and repeating Vietnam..."

The "Interdisciplinary Progress Notes" for Patient #3, written by a Registered Nurse (RN), documented, "3/10/16 2:50 p (PM) Pt [patient] found by tech on floor, unresponsive. Pt was reportedly 'cursing out' the roommate & the roommate struck him in the face. [Name of Patient #3] fell to floor, unresponsive, unsure if he hit his head. Brief LOC [loss of conscious] but did not lose pulse or resp [respirations]. BP [Blood Pressure] remained stable...Sent to [Name of Local Hospital]..."

Review of the "ED [Emergency Department] Physician Documentation" for Patient #3, from the acute hospital, dated 3/10/16 revealed, "The patient presents to the emergency department and reports being assaulted and Patient with PHM [Past Medical History] of schizophrenia D/O, HTN, hypothyroid, who comes to the ED after he was assaulted by another resident at [Name of Psychiatric Hospital] with a cast to his face. Staff reports + [positive for] LOC, but the patient denies...Associated symptoms: loss of consciousness." The Radiology report dated 3/10/16 revealed "Impression...Subarachnoid and Subdural Hemorrhage..."

Review of the acute hospital History and Physical Examination dated 3/10/2016 at 9:38 PM revealed, "... Chief complaint: Head Injury: History of present Illness: This is a [AGE]-year-old male with history of hypertension, [DIAGNOSES REDACTED], Schizoaffective disorder, resident of [Name of Psychiatric Hospital] who presented today after being involved in an assault with another resident at [Name of Psychiatric Hospital] per the staff, the patient had loss of consciousness...Radiology Studies: 1. Computed tomography [CT] scan of the head showed diffuse bilateral subarachnoid hemorrhage with Subdural hematoma overlying the left parietal and occipital lobes, non displaced fracture of the left maxillary sinus. 2. Computed tomography scan of the maxillofacial area without contrast showed nondisplaced fracture of the left maxillary sinus with some soft tissue air...The Assessment and Plan revealed, "This 69 -year-old-man with past history as stated above who was involved in an assault today. He is found to have bilateral subarachniod and subdural hematoma..."

Record review for Patient #5 (Patient involved in assault with patient #3) revealed the DOB as 4/25/1992. Patient #5 was admitted on [DATE] and discharged on [DATE]. Admitting diagnoses included [DIAGNOSES REDACTED]"Patient presented to [Name of Transferring Facility] by [Name of Police Department] with hearing impairment, paranoia, rambling speech and incoherent. Patient reports auditory hallucinations, stating someone was shooting at him. He was running from unseen person shooting at him, got into someone's car and was charged with carjacking. Patient continues to be paranoid and was observed drinking from the toilet.."

3. On 3/29/16 at 2:10 PM the surveyor met with the State Investigator (SI) in her office to review facility investigation because they could only be viewed on the SI computer The SI notified the facility attorney regarding what information the surveyor was permitted to review. Two open investigations were reviewed. Review of the investigation of the incident on 3/10/16 (assault by Patient #5 to Patient #3) revealed a description of the incident with no information on how or when the incident was investigated. Review of the facility Investigations Case Log revealed the assault of Patient #3 was listed with the incident date of 3/16/16, 6 days after the incident (not on the date it actually occurred).

During an interview in the conference room on 3/30/16 at 11:00 AM, the first Physician on site when the code was called for Patient #3 stated, "[Patient #3] had visible signs of injury to his face and to the back of his head...Patient [was] sent to the ER [emergency room ]..."

During in interview in the conference room on 3/30/16 at 2:01 PM, the Psychiatric Technician stated, "[Patient #5] was assigned to room with [Patient #3]. The unit was full and that was the only place to put the new patient [Patient #5]. I left the new patient in the room with [Patient #3] and went to get clothes for [Patient #5] so he could get a shower..." The Psychiatric Technician stated on his way back he heard a noise in the room and saw [Patient #3] on his back, in the floor, unconscious. He stated when he asked [Patient #5] if he hit [name of Patient #3]. He stated, "Yes"..."

During an interview in the conference room on 3/30/16 at 2:08 PM, the surveyor asked what the facility had done to prevent incidents like the assault between Patient #3 and Patient #5 from happening again. The Chief Executive Officer (CEO) stated, "This was an unpredictable situation. I don't know that we could have done anything different. In group that day [Patient #3] was very agitated. Patient could have benefited from a PRN (whenever needed medication). It was determined this was not a sentinel event... Relating to the patient's current condition, it is not directly related to the incident..."

During a telephone interview on 4/5/16 at 11:20 the CEO stated the facility had decided to do a RCA on the Patient to Patient assault that occurred on 3/10/16. The facility RCA was conducted 26 days after the incident occurred.

During in interview in the conference room on 4/18/16 at 9:40 AM, when the surveyor asked about the facility's Investigation policy for abuse (showing the CEO and Assistant Superintendent/Quality Management (AS/QM) the policy received on 3/29/16), the AS/QM stated that the policy had been revised and she was not sure if that policy was still effective. During a subsequent interview in the conference room on 4/18/16 at 10:40 AM, the AS/QM verified the facility still had the same abuse policy that the surveyor was given on 3/29/16.

During an interview in the conference on 4/18/16 at 9:35 AM with the DON and Nurse Educator, the surveyor asked about the incident between Patient #3 and Patient #5. The DON stated, "In this incident, the staff followed the policy. We see no need to change the policy, just the steps. We will re-educate the staff in that as soon as a patient arrives to the unit, patient and roommate are introduced and are monitored for interactions with the nurse present to see if they are suitable roommate..."

During an interview in the conference room on 4/18/16 at 10:40 AM the AS/QM stated, "The case was not investigated. There was no abuse or neglect. We would not have done the Abuse Policy of reporting time frames because it was not abuse or neglect. It was Patient to Patient. altercation." The AS/QM verified the facility still had the same abuse policy.

The investigation revealed Pt #3 (alleged victim/AV) was assaulted by another patient at the psychiatric hospital and was transferred to emergency room at an acute hospital were he was diagnosed with [DIAGNOSES REDACTED].