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.


Based on review of the Reportable Events document, the Tennessee Code Annotated, hospital policies and procedures, interpretative guidances, the hospital failed to ensure the patients' right to be free from abuse and harassment for 1 of 4 (Patients #3) sampled patients. The hospital failed to report this incident to the Tennessee Department of Health as mandated.

The findings included:

The hospital's "Patient Abuse and Neglect" policy effective 9/1/2015 documented, "...It is the policy of [Named Corporate Company] that no patient is to be mistreated or abused physically, verbally, psychologically or sexually while in our care...Examples of patient abuse include...striking a patient...rough handling of the patient...speaking inappropriately with a patient and threatening a patient..."

The hospital's "Incident Reporting" policy documented, "...An incident is defined as an unusual event involving a patient...The event is considered unusual if it was unintended, undesirable, and/or incident report must be filed for any of the following circumstance...An unusual event, which does or may result in personal and/or bodily injury...Any threat of personal harm or injury voiced by a...employee which requires precautionary actions to be taken...includes but is not limited to...Alleged or observed physical abuse of a patient by any staff member...PROCEDURE...Responsibility for completing an incident report rests with any staff member who witnesses, discovers or has direct knowledge of an incident...All Incident Reports are to be turned in to the Employee's Supervisor...and send the report to the Risk Manager...FOLLOW-UP...The Administrator/designee shall be responsible for follow-up of all incidents, analyses of all incidents and preparation of a monthly summary. Copies of the summary shall be submitted to the Safety Committee and the Board of Trustees. The reports and summaries shall be used to: 1) monitor the safety levels of the facility; 2) identify specific problem areas, which should be studied and recommend corrective action where needed; 3) identify areas for continued training; 4) identify trends..."

The hospital's "Incident Reporting" policy did not address incident reporting to the Department of Health.

Review of the document "Interpretive Guidelines for Reportable Events" revised July 2009 revealed, "Effective May 27, 2009, the Health Data Reporting Act of 2002 was amended by Public Acts of 2009, Chapter 318. The new law provides that all licensed health care facilities...shall only report incidents of abuse, neglect, and misappropriation that occur at the facility to the Department. For state licensure purposes, the facility is required to make the report within seven (7) business days from the date that the facility identifies the incident... Definitions...'Abuse' is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish..."

Review of State Operations Manual, Appendix A Survey Protocol, Regulations, and Interpretative Guidelines for Hospitals revealed, "...482.13(c)(3)... The intent of this requirement is to prohibit all forms of abuse...The hospital must ensure that patients are free from all forms of abuse, neglect, or harassment. Abuse is defined as the willful infliction of injury...intimidation...with resulting physical harm, pain, or mental anguish...The following components are suggested as necessary for effective abuse protection... Report/Respond. The hospital must assure that any incidents of abuse, neglect or harassment are reported..."

The "Tennessee Code Annotated Title 68...Chapter 11...Part 2..." documented, "...68-11-211...Reporting incidents of abuse, neglect...As used in this section..."Department" means the department of health..."Facility" means any facility licensed under this part..."Abuse" means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish...each facility shall report incidents of abuse...that occur at the facility to the department within seven (7) business days from the facility's identification of the incident...Nothing in this section shall be construed to eliminate or alter in any manner the required reporting of abuse...or any other provisions of...title 71, chapter 6, part 1..."

The "Tennessee Code Annotated Title 71...Chapter 6...Part 1..." documented, "...71-6-103...Any person, including, but not limited to, a physican, nurse...having reasonable cause to suspect that an adult has suffered abuse...shall report or cause reports to be made in accordance with this part...If a hospital...or any other organization or agency responsible for the care of adults has a specific procedure, approved by the director of adult protective services for the department, or the director's designee, for the protection of adults who are victims of abuse...any member of its staff whose duty to report under this part arises from the performance of the staff member's services as a member of the staff of the organization may, at the staff member's option, fulfill that duty by reporting instead to the person in charge of the organization or the organization head's designee who shall make the report in accordance with this chapter...An oral or written report shall be made immediately to the department [Department of Health] upon knowledge of the occurrence of suspected abuse...of an adult..."

The hospital confirmed this incident of abuse was not reported to the Department of Health.

Medical record review revealed Patient #3 was admitted on [DATE] with diagnoses of Schizoaffective Bipolar, Hypertension, Chronic Kidney Disease and Degenerative Joint Disease.

A patient observation form dated 9/4/18 revealed every 15 minute checks were done. Review of the observation form revealed Patient # was observed in his room, sitting or lying down at 1:45 PM, 2:00 PM, and 2:15 PM. These 3 observations were documented by Mental Health Technician #1. The documentation for 2:30 PM and 2:45 PM was left blank.

A patient care note dated 9/4/18 at 14:30 [2:30 PM] documented, "Behaviors: [Named Patient #3 ] physical aggressive to staff. Rt [right] arm swollen, cool to touch, denies pain to site, but stiffness noted per pt [patient]...X-ray to rt arm...continue with POC [Plan of Care]...9/9/18 at 23:02 [11:02 PM]...Patient assessed...Right arm swollen from antecubital area down [to] the wrist..."

An X-ray dated 9/4/18 at 15:52 [3:52 PM] documented, "...FOREARM, AP [Anterposterior- beams passing from front to back] AND LATERAL [x-ray taken from a side view] VIEWS, RIGHT...CONCLUSION...Apparent soft tissue swelling near distal humerus and proximal forearm..."
An X-ray dated 9/4/18 at 15:52 [3:52 PM] documented, "...HUMERUS, TWO VIEWS, RIGHT...CONCLUSION...Apparent soft tissue swelling near distal humerus and proximal forearm..."
An X-ray dated 9/4/18 at 21:14 [9:14 PM] documented, "...WRIST, THREE VIEW ROUTINE, RIGHT...CONCLUSION...Mild spurring and degenerative changes within the wrist..."

A "GENERAL COUNSELING/CORRECTIVE RECORD" dated 9/5/18 documented, "...Report of patient abuse. Suspended pending investigation..."

A "GENERAL COUNSELING/CORRECTIVE RECORD" dated 9/7/18 documented, "...After investigation termination was decided after reviewing video and interviewing staff..."

A "SEPARATION NOTICE" documented, "...circumstances of this separation: Policy Violation..."

A "Termination Information" form documented, "...Termination reason Policy Violation...Eligible for rehire No...Staff member had a physical altercation with a patient..."

The facility was unable to provide the video for review.

Interview with NM #1 on 11/26/18 at 2:06 PM, in the conference room, NM #1 stated, "...I know he [MHT #1] was terminated due to this incident."

Interview with the Director of Risk Management (DRM) on 11/26/18 at 5:02 PM, in the conference room, the DRM was asked who is responsible for reporting to the state. The DRM stated, "The persons who were responsible were the CNO and HR at that time for reporting to the State. They are no longer here. It is my understanding the Risk Manager is responsible, but I will discuss it with Corporate to make sure we have a plan..."

Telephone interview with MHT #2 on 11/28/18 at 8:46 AM, MHT #2 was asked what he saw the afternoon of 9/4/18 regarding Named MHT #1 and Named Patient #3. MHT #2 stated, "...I got to work early that day, about 2:30 PM, so I went ahead and clocked in early...I came in the door to the unit and I saw him [MHT #1] put his hands on the resident [Patient #3]. I put my stuff in the chair in the doorway and went in and broke it up. I got between them and I asked [Named MHT #1] to come out and I took Mr. [Named Patient #3] to the activity room...[Named MHT #1] was walking away. I stayed with him [Patient #3] my whole shift...You gotta let him out and walk and let out some frustration, I know Mr. [Named Patient #1] and he needs that. [Named MHT #1] came into the day room and he said to [Named Patient #3], "I know you don't want no more." MHT #1 was asked what did that mean. MHT #2 stated, "I took it to mean you don't want to mess with me no more..." MHT #2 was asked if he saw MHT #1 any time after that in the hospital. MHT #2 stated, "After I talked to the administrator, [same afternoon] I didn't see him anymore. I passed him when I was going in there [HR office] to write my statement."

Telephone interview with Registered Nurse (RN) #1 on 11/29/18 at 11:21 AM, RN #1 was asked if she saw the altercation. RN #1 stated, "No, I know about it because [Named MHT #1] told me...He was at the nurses' station and said [Named Patient #3] came out of the bathroom and hit him, so he pushed [Named Patient #3] against the wall and he fell to the floor on his right side..."