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 document review, interview and observation, the facility failed to protect patients from abuse and allowed staff to continue to work shift after incident of abuse in 1 of 10 medical records reviewed (Patient 1) (see tag 145).

The cumulative effect of this systemic problem resulted in the facility's inability to ensure that Patient Rights were promoted.
Based on document review, interview and observation, the facility failed to protect patients from abuse in 1 of 10 medical records reviewed (Patient 1).

1. Review of policy titled: Patient Rights and Responsibilities last revised 6/2018, indicated #18. "Receive care in a safe setting, free from verbal or physical abuse or harassment".

2. Review of policy: Patient Abuse and Neglect last reviewed 5/2019, indicated "All hospital employees have an obligation to protect patients, prevent abuse or neglect from occurring, and to report any and all information concerning occurrences where abuse or neglect may have occurred".

3. On 07/14/19 at 3.30 pm, Patient 1 requested to call family; family "already called and did not want to talk to" patient. Staff relayed information to patient; patient "upset, agitated and jumped on staff", family, Chief Executive Officer (CEO) and Interim Director of Nursing (DON) notified of incident. Staff administered Lorazepam 2 mg IM and Haloperidol 5 mg IM.

4. Interview on 07/18/19 at 11:08 am with P54, Human Resources [HR], confirmed receipt of phone call from Security on 07/15/19 at approximately 1:30 pm to watch the video of the date for 07/14/19 at approximately the time 3:30 pm. P54 confirmed, after watching video, termination of N2, N3,and N4 (each an Aide) occurred by 3:00 pm.

5. Interview on 07/18/19 at 11:10 am with P54, Human Resources, confirmed N2, N3 and N4 (each an Aide) seen in video of altercation with patient 1. N2 was sitting in chair and Patient 1 went after N2 when N2 put out leg to stop Patient 1. Patient 1 fell to floor, had a hold of N2's pocket, ripped it and N2 could be seen "stomping" the patient. N3 and N4 (both Aides) assisted.

6. Interview on 07/18/19 at 11:26 am with P54, Human Resources, confirmed the actions of N2, N3 and N4 (each an Aide) were not in line with CPI training and in violation of Patient 1's patient rights. N2, N3 and N4 were terminated on 07/15/19 between 2:30 pm and 3:00 pm.

7. Interview on 07/18/19 at 2:05 pm with P55, Registered Nurse [RN], Interim Director of Nursing, confirmed was Manager on duty and out of the building at time of incident. Received phone call from N8 Registered Nurse, regarding patient tried to attack staff; CPI hold used; gave patient 1 an injection; and returned to facility about the time patient 1 was transferred to another facility for care. Denied knowing about N2 (Aide) "stomping" Patient 1 until viewed the video.

8. Interview on 07/18/19 at 2:28 pm with P53, Chief Executive Officer (CEO), confirmed receipt of phone call regarding 2 falls, 1 bite and a patient incident; unable to provide name of who called regarding the incident. Call to CEO was made on 7/14/19 at approximately 3:40 pm.

9. Interview on 07/18/19 at 3:20 pm with N7 Aide, confirmed Patient 1 sitting on loveseat...wanted to talk to family...told that family did not want to talk to patient, only to focus on getting better...patient upset and cussing and then jumped up to attack N2 (Aide)...patient, N2 and N4 (Aide) on floor -- patient is kicking, spitting and fighting; eventually calmed down and went to room...patient threw furniture in room -- N4 got patient in bear hug...medication given.

10. Interview on 07/18/19 at 3:45 pm with N8 RN, confirmed did not witness the incident; was in Pyxis room getting medications for a patient; heard shouting and went out of nursing station; found patient 1 on floor with 2 Aides (N3 and N4), one was holding patient's head as patient was trying to bang head on floor; N2 jumped up to get out of altercation; "did not see incident in entity...reported only what I saw".

11. Review of video dated 07/14/19, no audio, on 07/18/19 at approximately 11:20 am showed Patient 1 getting up from loveseat and lunging toward N2; N2 put leg out to stop patient; N2 and Patient 1 tussle to the ground; N3 and N4 trying to get Patient 1 off of N2. At one point N2 raised right leg up in air and brought leg down and made a kicking movement, then one of the aide pulled or assisted N2 off of Patient 1. Unable to verify if N2's leg touched the patient. The video was from one point of view and lasted approximately 40 seconds.

12. Review of timecards indicated N2, N3, and N4 continued to work on 7/14/19, until N2 clocked out at 7:20 pm, N3 clocked out at 7:28 pm and N4 clocked out at 7:30 pm.

13. Review of documents and interviews indicated staff failed to report abuse after occurrance on 7/14/19.