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.
|BRATTLEBORO RETREAT||ANNA MARSH LANE PO BOX 803 BRATTLEBORO, VT||June 26, 2013|
|VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT||Tag No: A0145|
|Based on record review and staff interview the hospital failed to report to the appropriate State Agency allegations of abuse of one patient [Patient #2] of 7 patients in the sample group. Findings include:
1. Per record review of Nursing Notes from 5/28/13, a Mental Health Worker on the facility ' s Tyler 2 unit " reported that another peer, Patient #2, stated Patient #1 put his/her tongue in my mouth " .
Per record review Physician Progress Notes dated 5/29/13 document " Patient states h/she would like to leave today because h/she had a really rough day yesterday. States that a male peer Patient #1 ' stuck his tongue in my mouth while I was lying on the couch ' ...Tearful. States h/she feels unsafe, sharing space with Patient #1. "
Nursing Notes dated 5/31/13 record Patient #1 " pounding on [Adult Low Stimulation Area] door ...RN informed Patient #1 h/she' s here because h/she was French kissing a female " .
Per interview on 6/26/13 at 12:16 P.M. Patient #2 ' s Physician confirmed that the patient had spoken with h/her on 5/29/13 about the alleged assault, and that h/she shared this with Patinet #2 ' s treatment team the following morning [5/30/13]. The Physician confirmed that h/she is a mandated reporter and stated h/she assumed someone else on the treatment team would report the alleged assault.
Per interview with the Social Worker on Patient #2 ' s unit on 6/25/13 at 8:45 A.M., h/she was not aware of the incident, but the alleged assualt " should be reported " .
Per interview on 6/26/13 at 11:10 A.M. the Manager of Performance Improvement and Risk Management and the Nurse Manager on Patient #2 ' s unit both confirmed that staff members are mandated reporters, and someone on the staff should have reported the alleged assault to the appropriate State Agency but did not.