HospitalInspections.org

Based on record review and interview the facility failed to immediately report an allegation of caregiver abuse/misconduct in 1 of 1 caregiver misconduct allegations reviewed (Patient #1) in a total sample of 1 caregiver misconduct allegations reviewed.

Findings Include:

Review of the facility policy titled, "Caregiver Misconduct Management" dated 01/30/2024, revealed, "Staff and all other persons whom clients/patients come in contact shall treat the client/patient with courtesy, respect...shall provide them considerate care and treatment at all times... K. Abuse 1. An act...by a caregiver, including but not limited to restraint...that when contrary to...policies and procedures, when not a part of the patient's treatment plan... a. Causes or could reasonably be expected to cause pain, injury...B. Initial Assessment/Notification: 1. All staff and covered entities witnessing or having knowledge of... or possible alleged caregiver misconduct will report it immediately to the entities and their respective manager, including immediately contacting the respective [Hospital Name] Administrator on call if applicable. a. Prior to the call being made a plan of safety shall be executed immediately by the RN manager/Supervisor/designee to ensure the safety of the patient. d. ...House Supervisor on Duty will immediately contact the appropriate [Hospital Name] Administrator on Call Staff to ascertain and determine how investigations within the hospital will be conducted."

Patient #1 was a 35-year-old male who presented to the facility voluntarily on 06/16/2025 at 1:41 PM due to worsening depressive symptoms with active suicidal ideation.

A review of the facility's investigation summary involving Patient #1 revealed on 06/25/2025 at 11:00 PM Patient #1 was barricading door and exhibiting behaviors of increased agitation and self harm. Staff interventions were ineffective.
On 06/25/25 at 11:20 PM Patient #1 was placed in a secure hold and received chemical restraint.
On 06/26/25 at 12:05 AM Patient #1 was sent to the ED for treatment and evaluation of self inflicted wound.
On 06/26/25 at 4:30 AM CNO (Chief Nursing Officer) was informed of the event, an investigation was started.
On 06/26/2025 in the AM (No actual time documented) involved staff were suspended by leadership pending investigation.

Further review of the investigation revealed that Patient #1 was being held by two staff members who did not utilize proper CPI (Crisis Intervention Institute) training techniques, "By holding hands over mouth and pursing head into mattress." During the investigation process it was identified there were concerns about Milieu Specialist F's approach and making inappropriate statements which escalated Pt. #1's behavior. There was no evidence found that the facility staff reported the inappropriate hold or behavior to facility leadership until over 5 hours later.

On 08/12/2025 at 4:00 PM in an interview with CNO E when asked what was done to ensure patient safety and why this incident wasn't reported immediately to leadership CNO E stated, the incident that occurred on 06/25/2025 at 11:00 PM was brought to his attention on 06/26/25 at around 4:30 AM and an investigation was started. CNO E stated the investigation identified the staff involved acted inappropriately and, "This behavior is not tolerated."