HospitalInspections.org

Based on document review and staff interviews, the psychiatric acute care hospital's administrative staff failed to report 1 of 1 incidents of possible child abuse (Patient #1) in a timely manner. Failure to report an incident of possible child abuse in a timely manner to the applicable local and state agency may result in the administrative staff allowing a staff member to continue to work with mentally ill children after the staff member committed possible acts of child abuse. The hospital's administrative staff identified a census of 18 inpatients on the adolescent mental health unit, which treated children 12-17 years old, on entrance.


Findings include:


1. Review of policy, "Child, Adult at Risk and Elder Abuse and Neglect" dated effective June 12, 2020, revealed in part, "...All cases of known or suspected abuse are to be reported to the appropriate agency within 24 hours..."

2. Review of policy, "Patient Abuse and Neglect" dated effective June 12, 2020, revealed in part, "...To assess and evaluate any questionable or potential situations of abuse...and report...to the appropriate protective services under the guidelines of the federal and state regulations...Director of Compliance to ensure that all required reporting to regulatory...entities is completed within the required timeframe's and in accordance with federal and state law."

3. Review of incident report dated 5/17/22 at 4:12 PM, revealed in part, "...Date of Incident: 5/16/22 Time of Incident: 4:31 PM...Type of Incident: Other: Complaint received from patient to patient advocate....they were drug out of room on the unit by their legs,...[name of staff] was very mean...he grabbed me and threw me against the wall...Risk Manager Comments / Follow-Up: [name of individual] placed on Administrative Leave. HR/CEO conducting interviews with staff...video review and document review by QCR and QCR Specialist.

4. Review of incident report dated 5/18/22 at 2:30 PM, revealed in part, "...Date of incident: 5-16-22, Time of Incident: 4-5 PM...[name of staff] first grabbed patient's ankles...pulled patients pants off...took [patient]'s arm behind their back, not abiding by CPI [restraint training] ...wrapped arms around [patient] and tossed aggressively into seclusion room...[patient] slammed into wall and fell onto the floor."

5. During an interview on 5/24/22 at 11:15 AM, the Director of Quality, Compliance and Risk reported when the Director of Quality, Compliance, and Risk received the report regarding the incident on 5/16/22, the Director of Quality, Compliance, and Risk did not identify that the situation could possibly be viewed as abuse, as the incident didn't fit in the hospital policy's definition of abuse, as the staff member did not intend to harm a patient. The Director of Quality, Compliance, and Risk acknowledged that the federal regulations required the hospital staff to report within 24 hours all instances of possible abuse. The Director of Quality, Compliance, and Risk acknowledged they failed to report the possible instance of abuse to the appropriate state agency.

6. During an interview on 5/26/22 at 1:00 PM, the CEO acknowledged the facility failed to report possible child abuse following the allegations received.