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.

CHILD & ADOLESCENT BEHAVIORAL HEALTH SERVICES 1701 TECHNOLOGY DRIVE NE WILLMAR, MN 56201 June 8, 2020
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observation, interview, and document review, the hospital failed to ensure 1 of 10 patients reviewed (P1) was kept free from abuse when a hospital employee pushed her to the ground causing her to strike her head, and then verbally taunted her. As a result, the hospital was found out of compliance with the Condition of Participation - Patient Rights at 42 CFR 482.13.

A condition-level deficiency was issued.

Findings include:

See A-0145; Based on observation, interview, and document review, the hospital failed to ensure an allegation of physical abuse was identified and acted upon timely to provide patient protection and facilitate a timely investigation for 1 of 1 patients (P1) whom reported being physically pushed to the ground by a staff member causing her to strike her head. These findings constituted an immediate jeopardy (IJ) situation for P1 after the hospital failed to take systemic, timely action to ensure subsequent allegations were addressed in a thorough and timely manner.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on observation, interview, and document review, the hospital failed to ensure an allegation of physical abuse was identified and acted upon timely to provide patient protection and facilitate a timely investigation for 1 of 1 patients (P1) whom reported being physically pushed to the ground by a staff member causing her to strike her head. These findings constituted an immediate jeopardy (IJ) situation for P1 after the hospital failed to take systemic action to ensure subsequent allegations were addressed in a thorough and timely manner.

The IJ began on 5/26/20, when P1 entered the nurses station and was pushed down by the alleged perpetrator (a hospital employed behavioral analyst (BA)-A). As a result of being pushed, P1 struck her head on the floor which resulted in pain and discomfort. The incident was witnessed by other employees; however, it was not immediately reported to the administrator nor were required subsequent incident reporting steps completed which resulted in the AP continuing to work with P1 and other patients on an unsupervised basis increasing their risk of abuse and subsequent harm and/or injury. The hospital administrator, registered nurse supervisor (RN)-A, the medical director and the regional operations director were notified of the IJ for P1 on 6/5/20, at 12:19 p.m. The IJ was removed on 6/8/20, at 11:41 a.m., however, condition-level non-compliance remained.

Findings include:

P1's Person-Centered Master Treatment Plan dated 6/2/20, identified P1 admitted to the hospital in March 2020, and had several psychiatric diagnoses including major depression with psychotic features which had led to self-harm behaviors in the past. The plan outlined several barriers to P1's mental health which included a history of sexual abuse, and a lack of attention as a young child which lead to " ... an inadequate experience of attachment," and, " ... causes her emotional distress." Further, the treatment plan listed several interventions being completed for P1 while she was hospitalized including routine psychiatric practitioner visits, routine nursing visits to review coping skills, and twice weekly mental health professional visits.

P1's Vulnerability Risk Prevention Plan dated 6/3/20, identified P1 was over [AGE] years old, had trauma history and was vulnerable to abuse by others. A series of trauma triggers were identified which included, "People holding her down, especially males," which outlined a corresponding intervention which read, "If manual restraint is needed be verbal with [P1] about who is touching her and where." Further, the plan identified P1 was capable and likely to self-report incident(s) of abuse or neglect.

On 6/4/20, at 12:35 p.m. P1's guardian was interviewed. P1 had been at the hospital since March 2020, and they felt P1's care had been "really good" thus far. The guardian explained they had been contacted recently related to a couple of situations where P1 had been "acting out against the staff," however, they were unaware of specific details as they "don't get detailed reports as far as that goes." Further, P1's guardian voiced they were unaware of any incidents when P1 could have been physically assaulted while at the hospital, and they provided consent for P1 to be interviewed by the surveyor.

On 6/4/20, at 1:22 p.m. a tour of the hospital's only in-patient unit was completed with registered nurse (RN)-A present. The unit was a single hallway with patient rooms, bathrooms, and a single nurses' station which was closed off to the unit with a door which swung outward (into the hallway). There were no visible video camera system(s) present in the nurses' station, however, a camera was installed outside the station in the hallway which had a view of the nurses' station door. RN-A stated the camera's view was dependent on if the nurses station door was open or not; however, the system did record and could be viewable.

When interviewed on 6/4/20, at 1:33 p.m. P1 stated she had been at the hospital since March 2020. P1 was questioned about her care and treatment while at the hospital, and recalled an incident from approximately one week prior where a male staff member had pushed her down to the ground after she attempted to enter the nurses' station. P1 described the incident in detail where she voiced she had taken several steps inside the nurses station when this male staff member "shoved me back" causing her to fall down and "hit my head" which caused it to be sore. P1 identified the male staff member who pushed her down as behavioral analyst (BA)-A. Further, P1 stated BA-A had worked with her again since the incident where she was pushed, however, P1 voiced she wasn't concerned about him (BA-A) hurting her.

P1's progress note dated 5/26/20, at 9:25 p.m., was completed by RN-D. The note identified P1 had been sitting on her bed in her room attempting to calm down with two staff members present. P1 then abruptly stood and ran toward the nurses' station and attempted to gain entrance. The note outlined, "Staff blocked her entry to the office. [P1] and staff member's feet became tangled causing [P1] to fall back onto the floor and staff to stumble and almost fall." P1 was then restrained. A section labeled, "Face-To-Face Evaluation" which was completed due to P1 being restrained. The section outlined P1 attempted to enter the nurses' station and read, "Patient was blocked from entering office by male staff, patient and male staff's feet became tangled, [P1] landed on the floor and male staff stumbled almost falling." P1 was recorded as having no injuries. Further, the note listed all staff members whom were present which included clinical program therapist (CPT)-A.

A corresponding Minnesota DHS/DCT Incident Report Form - Detail, dated 5/26/20, identified P1 had been in her room when she abruptly stood up and ran out of her room to the nurses station. P1 attempted to enter the nurses station where three male staff were seated. The note continued, "As [P1] was entering the nurses office a staff attempted to block patient from entering the office," and P1 was restrained. There was no dictation which identified if abuse had potentially occurred. Further, the note had a section labeled, "Completion and Review," which identified the administrator had reviewed the report on 5/29/20, and marked it as, "No further action necessary."

During interview on 6/4/20, at 1:40 p.m. RN-C voiced she was unaware of any incidents which had occurred pertaining to P1 potentially being physically pushed to the ground, and added there were no circumstances where it would be acceptable to push a patient down onto the ground to her knowledge. RN-A stated the hospital made staff complete annual education on vulnerable adult/minors along with "the whole reporting whatever it's called." Further, RN-C stated she had not received any recent education on abuse reporting or the hospital's subsequent vulnerable adult and/or minor policies and procedures.

On 6/4/20, at 2:11 p.m. the recorded video feed from 5/26/20, was viewed with RN-A and the hospital administrator present. The feed was dated and time stamped from 5/26/20, at 9:18 p.m. which showed P1 leaving her room after a nurse, and running into the nurses' station as the door closed. As P1 ran into the nurses station, two female hospital staff members were seen immediately behind her as she entered the station. Approximately two seconds after P1 was no longer visible on the camera, due to being inside the nurses' station and the door being opened outward into the hallway. P1 became visible again as she was falling to the ground. P1 could be seen landing directly onto her back with her head making contact with the floor. P1 was then tended to by the same two visible female staff members. Approximately 80 seconds after P1 was visible falling onto the ground from the nurses' station doorway, BA-A can be seen walking out of the nurses station and down the hallway towards other patient rooms. The recorded video had no sound for the entirety of the footage.

At this time, the hospital administrator and RN-A were interviewed, and explained the nurse present in the tape (RN-D) was on leave of absence (LOA) for un-related reasons and not available for interview. The administrator described his reaction to the video footage, and stated the video showed P1 running into the nurses' station, and then P1 appeared to fall "backwards out the door." RN-A voiced she agreed, adding the video showed P1 "falling backwards and being restrained." They identified the two female staff members in the video, and verified one of them as being CPT-A. The administrator stated the incident had not been reported to him until 5/29/20 (three days later), when CPT-A voiced the concern as BA-A had "pushed [P1] backwards out of the nursing station." They had interviewed BA-A who denied pushing P1, moreover just attempting to block her entry to the station and being "caught off guard."

The administrator explained an incident report had been completed and he reviewed it, however, it did not mention any allegations of P1 being pushed, or other statements which would trigger someone to think abuse had potentially occurred. It was not until CPT-A had approached him on 5/29/20, where they voiced they had seen "a concerning incident" surrounding the 5/26/20, incident when P1 attempted to enter the nurses station. CPT-A had voiced BA-A had "pushed the patient backwards" when she entered the station which is what had caused her to fall to the floor. The administrator stated he then acted and removed BA-A from patient contact on 5/29/20, however, acknowledged it wasn't until CPT-A voiced their concerns to him days after the incident was it realized it was an allegation of abuse, and a subsequent vulnerable adult (VA) issue which they "needed to act on." The administrator outlined if someone observed an incident which could be patient abuse, they should make sure it's reported to him, and an incident report outlining the concerns should be completed, as these actions would facilitate a timely response including removing the AP from the situation and patient access. The administrator stated he was not sure why several days had went by before CPT-A made him aware of the incident. Further, the administrator voiced if he had been made aware of the incident sooner, he would have immediately removed BA-A from patient care, and started the investigation process sooner citing their "primary goal" was patient safety when abuse allegations were made.

A Critical Event Review and Action Guide, started 6/1/20 (five days after the incident), outlined a timeline of events surrounding the 5/26/20, incident with P1 and BA-A. The incident was listed as occurring on 5/26/20. On 5/27/20, the timeline identified, "Incident reported and briefly discussed by clinical team ... No mention made at this point of concerns related to this incident or staff interactions." On 5/29/20, several notes were listed which included the administrator completing an administrative review of the incident report (completed 5/26/20), CPT-A reporting the potential maltreatment and the administrator removing BA-A from direct patient care. The timeline identified a "formal investigation" as being requested on this date.

An untitled schedule listing, dated 5/13/20 to 6/9/20, was provided which outlined all the hospital staff names and shift(s) worked. BA-A was listed as working on 5/26/20, 5/27/20, 5/28/20, and 5/29/20.

On 6/4/20, at 3:04 p.m. BA-A was interviewed and recalled the incident from 5/26/20. BA-A stated P1 had been "ramping up" on the evening of 5/26/20, so he decided to wait in the nurses station. RN-D had then opened the nurses station doorway and started to enter when P1 ran through the doorway which caused him to hold his hands up in a 'stop motion' and voice, "Hey! Hey!" BA-A recalled P1 and him touching during the incident, however, he denied physically pushing her down explaining she must have tripped. BA-A stated he had spoken to P1, in person, since the incident and felt it was resolved; however, denied having received any re-education on abuse and/or vulnerable adult reporting since the incident happened adding he was moved to a different building and not helping patients at that time. Further, BA-A stated he was not supervised with his job or duties until he was removed from patient care on 5/29/20.

BA-A's personal file was reviewed. A Minnesota Department of Human Services (DHS) background study was completed on 12/5/17, which identified BA-A was cleared to work. An undated Individual Transcript of Learning Management System Recorded Data listing was provided which identified BA-A had completed EASE Physical Safety Strategies and Vulnerable Adult Mandated Reporting training(s) on 4/1/20, and 10/1/19, respectively. Further, no prior abuse disciplinary action(s) were identified, however, a single "letter of expectation" was present which was provided to BA-A on 1/8/20. This letter outlined several facility specific practices and processes which were expected of BA-A which included, "You will develop and maintain productive, effective, and professional working relationships with staff and patients." The letter outlined, "This letter should not be considered or perceived by you or others as discipline."

On 6/4/20, at 3:50 p.m. CPT-A was interviewed and verified she was present at the time of the incident on 5/26/20, involving BA-A and P1 in the nurses' station. P1 had ran into the nurses' station and CPT-A was "half a step" behind her when she entered. CPT-A voiced BA-A was present in the nurses station and proceeded to physically push P1 back which caused P1 to fall to the ground. BA-A then verbally stated to P1, "Are you gonna listen and go to your room now?" CPT-A stated P1 did not fall as a result of running into a block technique, but rather fell due to being physically pushed as she had observed the entire incident. CPT-A stated the whole incident had left her with an upset stomach, and she was concerned as BA-A had an overall authoritarian approach with patients at times, adding he sometimes was "very quick to raise the voice to be loud and make demands." CPT-A explained other patients, in the past, had even "made comments" about BA-A leaving black and blue marks on them or scratching patients on purpose; however, CPT-A was unable to recall a specific patient regarding these remarks, nor had she ever physically seen something as such until the 5/26/20, incident with P1. CPT-A stated she had reported her concerns to the administrator and medical director (MD)-A before adding, "They're well aware." CPT-A explained immediately following the incident on 5/26/20, the conversation in the nurses station between the employees whom witnessed the incident "didn't make me feel any better," as RN-D asked what had all happened to which someone replied, "I don't want to say he pushed her, but [ellipsis]." RN-D then voiced P1 must have bounced off BA-A's block to which everyone else agreed aside from CPT-A who voiced, "That is not what I saw." However, the conversation was then ended. CPT-A expressed she had not immediately reported the incident to the administrator as she had been injured during the incident on 5/26/20, however, she voiced she had reported the concern on the same night to the medical director and asked her to follow-up the next day. Further, CPT-A affirmed she felt P1 had been abused by BA-A during the incident on 5/26/20, when P1 was pushed to the ground.

On 6/5/20, at 9:22 a.m. the hospital administrator and medical director (MD)-A were interviewed. P1 had long-standing mental health needs which included a history of extreme depression and behavioral concerns, and this was the first time, to their knowledge, P1 had attempted to enter the nurses' station. MD-A stated CPT-A had texted her on the night of 5/26/20, and was "concerned about an interaction" they had witnessed where a staff member "had shoved" P1 out of the nurses station. MD-A voiced she proceeded to direct CPT-A to report the situation as a potential VA incident to which CPT-A stated she had "a day or so later," however, MD-A acknowledged she did not "nail down the specifics." MD-A reviewed the text message she had been sent which identified BA-A had shoved someone, and made a verbal comment which was, "Are you going to listen and go to you room[?]" The administrator stated he was unaware of that information.

MD-A stated BA-A making a verbal comment such as the text message outlined was not surprising as she had been aware of some concerns brought to her before involving BA-A as he was "very correctionally minded," and didn't always use "the best technique" when interacting with patients. MD-A voiced that mindset could have played a role into the 5/26/20, incident involving P1, and again reiterated there was some "therapeutic approach" concerns with BA-A in the past. The administrator stated he had heard some of the same concerns voiced by other staff members; however, there had never been any formal investigation or subsequent audits done of his care or techniques outside of just visualization when they are on the floor for other reasons. There had, however, been "multiple" conversations with him in the past due to his negative attitude with staff and facility process changes.

The administrator then explained the hospital policy on addressing witnessed or alleged abuse to it's patients. He voiced any completed incident reports should accurately reflect the situation and it's happenings; then the staff should have notified the administrator via telephone call, and completed a separate incident report outlining the allegations or witnessed abuse. They acknowledged there were procedures and processes in place which "we didn't follow" and should have including the accurate completion of required incident reports, the timely notification to the administrator and immediate protection of the patient to ensure they're free of abuse. MD-A voiced, in hindsight, a "more immediate, decisive response" should have been done.

A provided Vulnerable Adult Maltreatment Reporting policy dated 12/2019, identified a purpose of providing procedures for identifying and managing VA incidents including reporting and internally reviewing them. A section labeled, "Reporting Suspected Maltreatment," directed anyone observing maltreatment to immediately intervene and take whatever steps are needed to safeguard patients. The person then should report the incident either through a primary contact (i.e. the administrator) or contacting the Minnesota Adult Abuse Reporting Center (MAARC) directly; then complete an incident report per facility policy. The policy directed the primary contact would then assist in determining if the incident presents as a VA situation, and become reportable to the State agency (SA). Further, the policy directed internal review(s) of allegations would be completed within 30 calendar days.

The IJ which began on 5/26/20, was removed on 6/8/20, at 11:41 a.m. when the hospital had successfully submitted and implemented a removal plan which included screening all other patients for potential abuse concern(s), updating policies and procedures for abuse reporting and/or investigation, and educating staff on applicable policies and procedures. These items were verified as implemented on 6/8/20, from 10:00 a.m. to 11:40 a.m. through corresponding staff interview(s) and policy review.