HospitalInspections.org

Based on medical record review, video surveillance review, facility documents, patient and staff interviews, and review of facility policies and procedures, it was determined that the facility leadership failed to protect patients from all forms of abuse when one patient (P) (P#1) of four (P#2, P#3, & P#4) sampled patients was prevented from pulling at medical devices by a gentle slap on the hand.


Findings include:


A review of P#1's medical record revealed that P#1 was admitted to the facility on 2/10/25 at 4:29 p.m., with the diagnosis of Acute Hypoxic Respiratory Failure secondary to Aspiration Pneumonia (a medical condition where the body is unable to maintain adequate oxygen levels in the blood due to a sudden impairment of lung function).


Review of the Registered Nurse (RN) CC note dated 2/25/25 revealed clinical reason for restraint use, repeated attempts to remove life sustaining or pertinent lines, airway, or drains. Urgent patient safety concern, due to acute confusion or altered level of consciousness, alternative measures ineffective. Soft wrist restraints (left and right), toileting and hygiene needs offered and continually offered as needs were met and skin integrity and circulation were assessed and intact.


Video surveillance dated 2/14/25 beginning at 19:40 was reviewed with Director of Quality Management (DQM) GG on 3/11/25 at 1:45 p.m. and revealed P#1 alone in his room, lying in his bed with the bed linen disheveled and his legs in a bent position raised in the air. Continued observation revealed P#1's hand positioned near his throat.

At 19:40:55 Respiratory Therapist (RT) FF (identified by DQM GG) walked past P#1's room wearing dark color pants and top
At 19:41:05 Observed RT FF walk into P#1's room
At 19:41:10 RT FF walked over to P#1 and hit P#1's left hand one time using her right hand
At 19:41:13 P#1 appears to be questioning RT FF
At 19:41:16 RT FF appears to use radio
At 19:41:22 RT FF appears to make adjustments to P#1's trach tube
At 19:42:44 Observed Tech (identified by DQM GG) walk into P#1's room wearing light color pants and dark color shirt
At 19:43:08 Tech placed soft mittens on P#1
At 19:43:37 RT FF walks out of P#1's room


A review of DQM GG's investigation report concerning P#1 abuse allegation, which began 2/15/25 revealed facility management was notified on 2/16/25 by clinical liaison.
2/16/25 at 16:00 DQM GG spoke with P#1's wife.
2/17/25 DQM GG watched surveillance camera.
2/18/25 DQM GG watched additional surveillance camera footage. DQM GG's findings included: P#1 tried to decannulate himself at 19:41 on 2/14/25. RT FF entered the room to stop the patient's hand to prevent patient from decannulating himself.
2/19/25 DQM GG met with facility leadership
2/19/25 DQM GG met with P#1
2/19/25 DQM GG left voicemail for P#1's spouse
2/21/25 DQM GG mailed letter to P#1's spouse

A review of Director of Quality Management (DQM) GG's investigation report dated 2/26/25 revealed
12:30 p.m.: The following concerns were reported by family members of P#1:
-they want to know the name of the person who abused P#1
-P#1 was not being turned
-P#1 was not bathed often
-P#1 is dealing with delirium. P#1 reported to the family that five people came into his room and ripped his trach and leads off. They stated they know he had decannulated himself. The family members acknowledge that P#1 has delirium and has decannulated himself in the past.


DQM GG's findings are as follows:
-Per Chief Clinical Officer (CCO) BB, as of 2/26/25 P#1 was bathed on the following schedule (for full baths) on 2/17/25, 2/18/25, 2/20/25, 2/21/25, 2/24/25, and 2/26/25.
-Per CCO BB, P#1 is a self-turner and typically does not need to be turned since he is able to physically turn himself as he does often. He does have a sacral wound, that is currently improving.


An interview was conducted with P#1 on 3/10/25 at 3:50 p.m. in room 206 at the facility. During the interview P#1's spouse was present sitting in a chair next to P#1 who was lying in his bed. P#1 stated that the staff are treating him better now, but when he first arrived a nurse hit him. He continued to say he now feels better being at the facility. P#1's spouse stated that things have gotten better since P#1 was admitted a few weeks ago. She continued to say that she has advised the staff at the facility that she would prefer to bathe P#1, and they will allow her to do so. P#1's spouse stated that she was not present when the other incidents with the remote control and dirty linen took place. She continued to say that she has not had an issue with bathing P#1 or with clean linen at the facility.


An interview was conducted with Chief Executive Officer (CEO) AA on 3/11/25 at 9:45 a.m.in the administration conference room. CEO AA stated that she expected the State to come to the facility after receiving a complaint from P#1's family earlier this month. She continued to explain that P#1's family had expressed their dissatisfaction with the services they were receiving at the facility and that they were planning to file a complaint with the State of Georgia. CEO AA stated that after receiving the complaint from P#1's family DQM GG started the investigation process. She continued to explain that after DQM GG's investigation, which included reviewing the surveillance video from P#1's room, there was an incident where a Respiratory Therapist (RT) passed by P#1's room as saw him trying to remove his tracheotomy tube. The RT went into his room to stop him from decannulating himself and called for help. CEO AA stated that the RT who stopped P#1 from removing his tube had worked at the facility for a number of years and did nothing wrong. She continued to say that P#1's family continues to ask for the RT to be fired. CEO AA stated that there is no way they would terminate the RT.


An interview was conducted with Director of Quality Management (DQM) GG on 3/11/25 at 2:00 p.m. in the administration conference room. After reviewing the video surveillance with DQM GG, Respiratory Therapist (RT) FF walk into P#1's room and hit him on his hand. DQM GG stated that RT FF did nothing wrong in preventing P#1 from decannulation (the process to remove tracheotomy tube) himself at the time. She continued to explain that she concluded her investigation into patient abuse after reviewing the surveillance video, speaking with the RT FF's manager, speaking with P#1 and P#1's spouse and determined there was no harm.


An interview was conducted with Registered Nurse (RN) DD on 3/11/25 at 2:45 p.m. in the administration conference room. RN DD stated that she was familiar with P#1 and his family after caring for P#1 approximately six weeks ago. She continued to say that she did not have any issues with P#1 during the time she cared for him. She continued to explain that if a patient is continuously pulling at their tracheostomy (tube inserted through the opening and into the windpipe) tube, it is important to redirect the patient and try to explain why it must stay in. She continued to explain that if the patient continues to pull at the trach than soft mittens can be used. RN DD stated that it is also important not to approach a patient who is pulling on their trach aggressively as that could cause harm to both the patient and the nurse. RN DD stated it is best to approach a patient in a calm manner and gently remove his hands from the trach tube and place soft mittens on their hands if necessary. She continued to explain that what she can recall during the time she cared for P#1, he was able to self-rotate without assistance. She continued to explain that P#1's spouse who was visiting most days preferred to bath and clean P#1.


A telephone interview was conducted with Respiratory Therapist (RT) FF on 3/13/25 at 9:45 a.m. RT FF stated that she was familiar with P#1 and did recall the day she prevented P#1 from removing his tracheostomy (trach) tube. RT FF recalled that she observed P#1 fumbling with his trach and he nearly removed it. She continued to explain that she attempted to explain to P#1 that he could not do that, but he appeared to be confused. RT FF stated that when she realized that P#1 was in a confused state she gently removed his hand from his trach and called for assistance. She continued to explain that once the tech arrived she placed soft mittens on P#1 and then she exited P#1's room.


A review of the facility's policy titled "Patient Rights," Policy # PR.01, last revised August 2019 revealed All patients of Landmark Hospital have the right to receive care without discrimination due to age, gender, gender identity, race, color, religion, sexual orientation, income, education, national origin, ancestry, marital status, culture, language, disability, or who will pay the bill. In addition, the patient has a right to safe, respectful and dignified care at all times. 6. Care Delivery. A. Patients have a right to receive kind, respectful, safe, quality care delivered by skilled staff where high professional standards are continually upheld and reviewed. B. Patients have a right to receive care in a setting that is safe and free from any form of abuse, harassment or neglect. 9. Patient Complaints and Grievances. A. The hospital is committee to treating all patients with compassion and dignity; sometimes despite best intentions, problems may arise. We encourage patients and their family members to first discuss any concerns with their physician or ask to speak to the manager. B. The patient has a right to the review of quality of care concerns, insurance coverage decisions and concerns about discharge from the hospital. C. Patients have a right to expect a timely response from the hospital related to any complaint or grievance that may be made in person, by phone or in writing. The hospital has a duty to respond to these complaints or grievances in a manner the patient or their representative can understand.