HospitalInspections.org

Based on interview and record review, one patient reviewed (Patient #2) was not provided care in a safe setting.

Patient #2 was forcefully placed in the seclusion room by being pushed and grabbed on the back of his gown by a mental health tech (Personnel #10).

Findings included:

Patient #2's medical record reflected he was a 53 year old male with diagnoses that included Organic Affective Disorder and Dementia. Nursing and Physician notes reflected Patient #2 was agitated, aggressive, and combative with staff. The medical record of Patient #2 included he was transferred to an acute care medical center on 10/05/10 for a laceration to his eyebrow.

Review of nurses notes from the evening of 10/04/10 through 10/05/10 revealed no documentation of any special events that took place for Patient #2 that could have caused his laceration.

On 10/05/10 the physician noted the patient allegedly fell in the early morning resulting in a laceration to his eye.

During a confidential interview it was alleged that Patient #2 was mistreated by Personnel #10 during a restraint hold and while placing the patient in seclusion on 10/05/10. He/She stated he/she believed the mistreatment rose to the level of abuse and required reporting. It was alleged this mistreatment was on the facility's security video tape as well.

Personnel #5 was interviewed on 10/18/10 at 3:30 PM and stated she reviewed the tape because Patient #2 was taken to the hospital with a laceration to his head. Personnel #5 stated she and Personnel #6 reviewed the tape together. Personnel #5 stated Personnel #10 did not follow facility restraint protocol and specifically the type of hold Personnel #10 used on Patient #2. She stated when Personnel #6 attempted to speak with Personnel #10 about the incident he refused to discuss the matter and submitted his resignation.

On 10/20/10 in the afternoon Personnel #6 (Nurse Supervisor) was interviewed and confirmed she reviewed the tape of the event on 10/05/10 with Personnel #5. She stated it was clear Personnel #10 did not follow the facility policy for restraining a patient. Personnel #6 stated Patient #2 was very combative and Personnel #10 attempted to redirect the patient and the patient attempted to hit Personnel #10. She stated Personnel #10 grabbed the back of the patient's gown and attempted to put him in the seclusion room. She believed Personnel #10 and the patient then tripped over each others feet and they both fell to the floor. When she approached Personnel #10 about the even he refused to speak with her and turned in his resignation.

Personnel #7 (Nurse Supervisor) was interviewed the afternoon of 10/20/10 and stated she reviewed the tape of 10/05/10 as well and the facility restraint protocol was not followed. She confirmed the same events as stated above. She believed this rose to the level of abuse and should have been reported to Nursing Administration.

The facility's policy entitled "Abuse and Neglect" last revised January 2010 reflected, "...Definitions: A. Patient Abuse 1. Class I Abuse Any act or failure to act done knowingly, recklessly, or intentionally, including incitement to act, which caused or may have caused major physical injury to a patient...."

Based on interview and record review, the facility failed to ensure one patient reviewed (Patient #2) was not secluded or physically restrained without first receiving doctors orders to do so.

Patient #2 was forcefully placed in the seclusion room by being pushed and grabbed on the back of his gown by a mental health tech (Personnel #10).

Findings included:

Patient #2's medical record reflected he was a 53 year old male with diagnoses that included Organic Affective Disorder and Dementia. Nursing and Physician notes reflected Patient #2 was agitated, aggressive, and combative with staff. The medical record of Patient #2 included he was transferred to an acute care medical center on 10/05/10 for a laceration to his eyebrow.

Review of nurses notes from the evening of 10/04/10 through 10/05/10 revealed no documentation of any special events that took place for Patient #2 that could have caused his laceration.

On 10/05/10 the physician noted the patient allegedly fell in the early morning resulting in a laceration to his eye.

During a confidential interview it was alleged that Patient #2 was mistreated by Personnel #10 during a restraint hold and while placing the patient in seclusion on 10/05/10. He/She stated he/she believed the mistreatment rose to the level of abuse and required reporting. It was alleged this mistreatment was on the facility's security video tape as well.

Personnel #5 was interviewed on 10/18/10 at 3:30 PM and stated she reviewed the tape because Patient #2 was taken to the hospital with a laceration to his head. Personnel #5 stated she and Personnel #6 reviewed the tape together. Personnel #5 stated Personnel #10 did not follow facility restraint protocol and specifically the type of hold Personnel #10 used on Patient #2. She stated when Personnel #6 attempted to speak with Personnel #10 about the incident he refused to discuss the matter and submitted his resignation.

On 10/20/10 in the afternoon Personnel #6 (Nurse Supervisor) was interviewed and confirmed she reviewed the tape of the event on 10/05/10 with Personnel #5. She stated it was clear Personnel #10 did not follow the facility policy for restraining a patient. Personnel #6 stated Patient #2 was very combative and Personnel #10 attempted to redirect the patient and the patient attempted to hit Personnel #10. She stated Personnel #10 grabbed the back of the patient's gown and attempted to put him in the seclusion room. She believed Personnel #10 and the patient then tripped over each others feet and they both fell to the floor. When she approached Personnel #10 about the even he refused to speak with her and turned in his resignation.

Personnel #7 (Nurse Supervisor) was interviewed the afternoon of 10/20/10 and stated she reviewed the tape of 10/05/10 as well and the facility restraint protocol was not followed. She confirmed the same events as stated above. She believed this rose to the level of abuse and should have been reported to Nursing Administration.

Review of patient #2's medical record did not include physician orders for seclusion.

The facility's policy entitled "Abuse and Neglect" last revised January 2010 reflected, "...Definitions: A. Patient Abuse 1. Class I Abuse Any act or failure to act done knowingly, recklessly, or intentionally, including incitement to act, which caused or may have caused major physical injury to a patient...."