HospitalInspections.org

Based on document review and interview the facility failed to ensure a patient was free from abuse in one (1) instance (Patient # 10), failed to ensure a patient was free from abuse in one (1) instance (patient # 10), and failed to ensure an employee completed a refresher course related to appropriate hold/restraint techniques in one (1) instance. (D # 2-Interim Director of Nursing)

The cumulative effect of this systemic problem resulted in the facility's inability to ensure that Patient Rights were promoted.

Based on document review and interview, the facility failed to ensure a patient was free from abuse in one (1) instance (Patient # 10); failed to ensure an allegation of physical abuse toward a patient was appropriately investigated, analyzed and reported to the necessary agencies in accordance with applicable laws in one (1) instance. (Patient # 10)

Findings include:

1. The facility policy titled, Patient Rights and Responsibilities, PolicyStat ID 13517670, indicated on page three (3) - section Procedure - number eighteen (18) - Receive care in a safe setting free from verbal or physical abuse or harassment. This policy was last revised on 09/2021.

2. The facility policy titled, Patient Abuse and Neglect, no policy number, indicated on page one (1) - section - Purpose - To provide procedures for reporting, investigating, and following up on an allegation of patient abuse - on page two (2) - section - Definitions - Investigator - The person or persons assigned to find facts about an incident or allegation of abuse - on page three (3) - Procedure - Obtain initial written statements; an internal investigation form will be completed by the Hospital CEO, Human Resource Director, and/or Director of Quality. Copies of the completed internal investigation form, video clip, written statements, incident report, nursing notes (if applicable) - on page four (4) - will be reviewed by the Hospital Director of Quality and CEO no more than 24 hours after the initial 72 hours investigation period for review and signature after verifying accuracy - section - Reporting - The Director of Quality or Designee will notify their State Department of Mental Health and Addiction Licensing Agency and any additional required accrediting or licensing bodies if patient abuse and/or neglect is substantiated. Addiditionally, this policy does not remove the requirement of a mandated reporter to report incidents of abuse, neglect, etc. of an endangered or at risk patient (as defined by State Law) to all required social service agencies and other entitiies, including but not limited to APS, CPS, the State Attorney General, etc. This policy was last revised on 04/2024.

3. The facility policy titled, Restraint or Seclusion Use, Policy ID 13483128, indicated on page one (1) - section Policy - interventions, holds, and seclusion only to protect the immediate physical safety of the patient. This policy was last revised on 01/2025.

4. Incident Report dated 03/03/2025 at 10:35 am indicated while on one (1) to one (1) - 300 unit - unprovoked act - intentional act - supervisor/family notified - patient # 10 began peeling the window covering off the windows and placing it around his/her neck. Staff responded immediately, patient became aggressive attempting to continue self-harm. Patient # 10 refused oral medication for anxiety then became aggressive with intramuscular (IM) injection attempts. The patient took himself/herself to the ground during his/her aggressive behavior. He/she began hitting, kicking and reportedly biting staff. Staff used the physical hold Handle with Care (HWC) technique while the patient was on his/her back. The patient began spitting at staff. The patient continued to display aggression while on the floor in the hold which lasted over an hour because the patient would not calm down even with IM's. Patient was placed in seclusion at 11:33 am. The incident report lacked any documentation of improper hold/technique/patient abuse.

5. Review of the closed medical record for patient # 10 indicated the patient was a 20 y/o (year/old) admitted to H # 2's (Psychiatric Hospital) inpatient unit on 01/27/2025. The patient's diagnoses included, but were not limited to, major depressive disorder, severe without psychotic features, suicidal ideation, and attention deficit hyperactivity disorder (ADHD). The Daily Nursing Assessment dated 03/03/2025 at 10:20 am the patient began hitting, kicking, and attempting to bite staff. Patient took self to floor during aggression and snatched a staff member around the head. The patient began spitting at staff. At 10:52 am the patient was administered another IM injection, but he/she became increasingly aggressive with failed attempts to de-escalate. At 11:15 am the patient remained on the floor with staff assisting (holding arms and legs) due to the increased aggression displayed by the patient. The patient was swinging arms, kicking staff while he/she continued to spit/attempt to bite. At 11:32 am another IM injection was administered. The patient agreed to cooperate with staff by getting up and once standing up he/she became aggressive, seclusion was ordered, and patient was placed in seclusion.

6. In interview on 04/03/2025 at approximately 11:45 am with unlicensed staff member B # 2, confirmed he/she was at the code with patient # 10, and witnessed D # 2 (Interim Director of Nursing-DON) place his/her hands on the patient's throat choking him/her. The patient's face turned dark red.

7. In interview on 04/03/2025 at approximately 12:30 pm with unlicensed staff member H # 11, confirmed he/she was assisting with the physical hold of patient # 10 on 03/03/2025. D # 2 was trying to put a mask on patient # 10 when he/she tried to bite D # 2. The patient was wheezing, and I heard D # 2 say, "you will be okay ...you will be able to breathe once I let you go". H # 11 looked up because what D # 2 said and the patient's face was purple/blue. We all have been bit before but never took it that far. That was too far.

8. In interview on 04/03/2025 at approximately 1:45 pm with unlicensed staff member P # 2, confirmed he/she was present for the code on 03/03/2025 with patient # 10. The patient was spitting so he/she wasn't looking at the patient but heard the patient gasping for air and wheezing.

9. In interview on 04/03/2025 at approximately 3:45 pm with administrative staff member A # 1 (Chief Executive Officer-CEO), confirmed he/she should have looked/reviewed at the collected information related to the 03/03/2025 accusation of patient abuse before telling Human Resources it was okay for D # 2 to return to work.

10. In interview on 04/04/2025 at approximately 8:45 am with administrative staff member A # 1, confirmed H # 2 references the Abuse and Neglect policy when allegations of abuse between staff and patients occur. H # 2 changed staff training from CPI to HWC training. It's all the same intervention/prevention/de-escalation/hold techniques.

11. In a phone interview on 04/04/2025 at approximately 11:20 am with licensed staff member A # 6, confirmed he/she reported the abuse allegation to A # 1, A # 3 (Director of Quality), and A # 5 (Human Resource Director) immediately. B # 2 was shaken up when he/she was telling me what happened during the code. The week before the abuse allegation occurred, I sent an email to A # 1 which indicated that I believed that D # 2 was acting inappropriately to patient # 10 and suggested that D # 2 work on a different unit.

12. In interview on 04/04/2025 at approximately 12:12 pm with unlicensed staff member B # 5, confirmed he/she was present at the code for patient # 10 was in the physical hold on 03/03/2025. D # 2 was holding the patient's jaw/upper throat and told the patient that he/she could breathe once he/she let go. The patient sounded like they couldn't breathe, and the patient's face was red/blue. It seemed like it lasted for about two (2) minutes. B # 5 stated that he/she was not taught to hold a patient on or near the throat.

13. In interview on 04/07/2025 at approximately 3:07 pm with administrative staff member A # 1, confirmed he/she should have been more involved with the investigation of patient # 10's abuse allegation which occurred on 03/03/2025. The witness statements were not obtained correctly regarding the allegation of patient abuse. We should have completed an incident report, and we should have reported the abuse to the necessary agencies (licensing board, APS, Attorney General and DMHA),

Based on document review and interview the registered nurse failed to complete a mandated refresher course related to Handle with Care (HWC) in one (1) instance. (D # 2 - Interim Director of Nursing)

Findings include:

1. The facility policy titled, Staff Competencies, PolicyStat ID: 12507941, indicated on page one (1) - section - Policy - Competence may be assessed through discipline specific skills check lists - on page two (2) - section - Consequences for Not Meeting Competency Requirements - number one (1) - When a staff member's competency does not meet the requirements, the employee will be given education and may be placed on a performance improvement plan. This policy was last revised on 01/2020.

2. Review of Personnel files for D # 2 (Interim DON), indicated a Disciplinary Action Notice Form dated 03/03/2025 - Counseling - Findings - During a patient restraint, the use of an incorrect hold was performed. As a result of the violation of proper procedure, D # 2 is required to complete a refresher course with HWC (Handle with Care) before assisting with any future codes. Attendance is mandatory. The Personnel file for D # 2 lacked documentation of a completed refresher course.

3. In interview on 04/07/2025 at approximately 4:40 pm with administrative staff member A # 5, confirmed D # 2 stated that he/she was not going to complete the HWC refresher course, even though it had been mandated. D # 2 had been on over six (6) codes since 03/03/2025.

Based on document review and interview, the facility failed to ensure the patient care units were adequately staffed to provide nursing care to all patients as needed on three (3) patient care units. (Units-100, 200 & 300)

Findings include:

1. The facility policy titled, Clinical Staff (Nurse) Staffing Plan, no policy number, indicated on page one (1) - Section - Purpose - This policy is to establish guidelines for providing sufficient numbers and mix of staff necessary to provide multidisciplinary patient care that is consistent with the assessed needs of the population served. This policy was last revised on 09/2024.

2. The facility Sample Staffing Grid by shift, indicated nurses work a twelve (12) hour shift and BHA's (Behavioral Health Associate) work eight (8) hour shifts.

3. Review of the facilities "staffing pattern worksheet" and "daily census sheet" provided by the facility, indicated the 100, 200, and 300 units were short staffed by staffing guidelines during the week of 03/02/2025 through 03/08/2025 and during the week of 04/03/2025 through 04/07/2025 on the following dates/shifts:

100 Unit:
a. On 03/02/2025 - Day shift (7:00 am - 7:00 pm) - Patient Census - 26 - the unit was staffed with two (2) nurses and per facility guidelines they should have had three (3) nurses. The shift was short staffed one (1) nurse. Night shift (11:00 pm - 7:00 am) - the unit was staffed with one and a half (1.5) BHA's (Behavioral Health Associate) and per facility guidelines they should have had two (2) BHA's. The shift was short staffed one (1) BHA.
b. On 03/03/2025 - Day shift - Patient Census - 26 - the unit was staffed with one and a half (1.5) nurses and per facility guidelines they should have had three (3) nurses. The shift was short staffed one and a half (1.5) nurses. Night shift - the unit was staffed with one (1) BHA and per facility guidelines they should have had two (2) BHA's. The shift was short staffed one (1) BHA.
c. On 03/04/2025 - Day shift - Patient Census - 26 - the unit was staffed with two (2) nurses and per facility guidelines they should have had three (3) nurses. The shift was short staffed one (1) nurse. Evening shift (3:00 pm - 11:00 pm) - the unit was staffed with two and a half (2.5) BHA's and per facility guidelines they should have had three (3) BHA's. The shift was short staffed a half (0.5) BHA.
d. On 03/06/2025 - Day shift - Patient Census - 26 - the unit was staffed with two (2) nurses and per facility guidelines they should have had three (3) nurses. The shift was short staffed one (1) nurse.
e. On 03/07/2025 - Day shift - Patient Census - 25 - the unit was staffed with three (3) BHA's and per facility guidelines they should have had four (4) BHA's. The shift was short staffed one (1) BHA. Evening shift - the unit was staffed with two and a half (2.5) BHA's and per facility guidelines they should have had four (4) BHA's. The shift was short staffed by one and a half (1.5) BHA's. Night shift - the unit was staffed with one (1) BHA and per facility guidelines they should have had two (2) BHA's. The shift was short staffed one (1) BHA.
f. On 03/08/2025 - Day shift - Patient Census - 25 - the unit was staffed with three (3) BHA's and per facility guidelines they should have had four (4) BHA's. The shift was short staffed one (1) BHA. Evening shift - the unit was staffed with two (2) BHA's and per facility guidelines they should have had four (4) BHA's. The shift was short staffed two (2) BHA's. Night shift - the unit was staffed with one (1) BHA and per facility guidelines they should have had two (2) BHA's. The shift was short staffed one (1) BHA.
g. On 04/05/2025 - Day shift (7:00 am - 3:00 pm) - Patient Census - 21 - the unit was staffed with two (2) BHA's (Behavioral Health Associate) and per facility guidelines they should have had three (3) BHA's. The shift was short staffed one (1) BHA.
h. On 04/06/2025 - Day shift - Patient Census - 23 - the unit was staffed with two (2) BHA's and per facility guidelines they should have had four (4) BHA's. The shift was short staffed two (2) BHA's.

200 Unit:

a. On 03/02/2025 - Day shift (7:00 am - 7:00 pm) - Patient Census - 26 - the unit was staffed with two (2) nurses and per facility guidelines they should have had three (3) nurses. The shift was short staffed one (1) nurse. Day shift (7:00 am - 3:00 pm) was staffed with two (2) BHA's and per facility guidelines they should have had four (4) BHA's. The shift was short staffed two (2) BHA's. Evening shift (3:00 pm - 11:00 pm) - the unit was staffed with one (1) BHA and per facility guidelines they should have had three (3) BHA's. The shift was short staffed two (2) BHA's. Night shift (11:00 pm - 7:00 am) - the unit was staffed with one (1) nurse (working as BHA) and per facility guidelines they should have had two (2) BHA's. The shift was short staffed one (1) BHA.
b. On 03/03/2025 - Day shift - Patient Census - 26 - the unit was staffed with two (2) nurses and per facility guidelines they should have had three (3) nurses. The shift was short staffed one (1) nurse. Day shift - the unit was staffed with two and a half (2.5) BHA's and per facility guidelines they should have had three (3) BHA's. The shift was short staffed by a half (0.5) BHA. Night shift (11:00 pm - 7:00 am) - the unit was staffed with one (1) nurse (working as BHA) and per facility guidelines they should have had two (2) BHA's. The shift was short staffed one (1) BHA.
c. On 03/04/2025 - Day shift - Patient Census - 26 - the unit was staffed with two (2) nurses and per facility guidelines they should have had three (3) nurses. The shift was short staffed one (1) nurse. Night shift - the unit was staffed with one (1) BHA and per facility guidelines they should have had two (2) BHA's. The shift was short staffed one (1) BHA.
d. On 03/05/2025 - Day shift - Patient Census - 25 - the unit was staffed with three (3) BHA's and per facility guidelines they should have had four (4) BHA's. The shift was short staffed one (1) BHA. Evening shift - the unit was staffed with three (3) BHA's and per facility guidelines they should have had four (4) BHA's. The shift was short staffed one (1) BHA.
e. On 03/06/2025 - Day shift - Patient Census - 24 - the unit was staffed with three (3) BHA's and per facility guidelines they should have had four (4) BHA's. The shift was short staffed one (1) BHA. Evening shift - the unit was staffed with three (3) BHA's and per facility guidelines they should have had four (4) BHA's. The shift was short staffed one (1) BHA.
f. On 03/07/2025 - Evening shift - Patient Census - 20 - the unit was staffed with one and a half (1.5) BHA's and per facility guidelines they should have had three (3) BHA's. The shift was short staffed by one and a half (1.5) BHA's.
g. On 03/08/2025 - Day shift - Patient Census - 20 - the unit was staffed with two (2) BHA's and per facility guidelines they should have had three (3) BHA's. The shift was short staffed one (1) BHA.
h. On 04/03/2025 - Evening shift (3:00 pm - 11:00 pm) - Patient Census - 22 - the unit was staffed with two (2) BHA's and per facility guidelines they should have had three (3) BHA's. The shift was short staffed one (1) BHA.
i. On 04/04/2025 - Evening shift - Patient Census - 23 - the unit was staffed with two (2) BHA's and per facility guidelines they should have had four (4) BHA's. The shift was short staffed two (2) BHA's.
j. On 04/04/2025 - Night shift (11:00 pm - 7:00 am) - Patient Census - 23 - the unit was staffed with zero (0) BHA's and per facility guidelines they should have had one (1) BHA. The shift was short staffed one (1) BHA.
k. On 04/05/2025 - Day shift - Patient Census - 23 - the unit was staffed with one (1) nurse and per facility guidelines they should have had two (2) nurses. The facility was short staffed one (1) nurse. Evening shift - the unit was staffed with two (2) BHA's and per facility guidelines they should have had four (4) BHA's. The shift was short staffed two (2) BHA's.
l. On 04/06/2025 - Day shift - Patient Census - 25 - the unit was staffed with two (2) BHA's and per facility guidelines they should have had four (4) BHA's. The shift was short staffed two (2) BHA's. Evening shift - the unit was staffed with two (2) BHA's and per facility guidelines they should have had four (4) BHA's. The shift was short staffed two (2) BHA's. Night shift - the unit was staffed with one (1) BHA and per facility guidelines they should have had two (2) BHA's. The shift was short staffed one (1) BHA.
m. On 04/07/2025 - Day shift - Patient Census - 25 - the unit was staffed with one (1) nurse and per facility guidelines they should have had two (2) nurses. The shift was short staffed one (1) nurse. Day shift - the unit was staffed with two (2) BHA's and per facility guidelines they should have had four (4) BHA's. The shift was short staffed two (2) BHA's. Evening shift - the unit was staffed with two (2) BHA's and per facility guidelines they should have had four (4) BHA's. The shift was short staffed two (2) BHA's.

300 Unit:
a. On 03/02/2025 - Evening shift (3:00 pm - 11:00 pm) - Patient Census - the unit was staffed with one and a half (1.5) BHA's and per facility guidelines they should have had two (2) BHA's. The shift was short staffed by a half (0.5) BHA.
b. On 04/03/2025 - Evening shift - Patient Census - 11 - the unit was staffed with one (1) BHA and per facility guidelines they should have had two (2) BHA's. The shift was short staffed one (1) BHA.
c. On 04/04/2025 - Evening shift - Patient Census - 12 - the unit was staffed with one (1) BHA for the entire shift and one (1) BHA for half of the shift (until 7:00 pm) and per facility guidelines they should have had two (2) BHA's. The shift was short staffed one (1) BHA for four (4) hours.
d. On 04/05/2025 - Day shift - Patient Census - 10 - the unit was staffed with one (1) BHA and per facility guidelines they should have had two (2) BHA's. The shift was short staffed one (1) BHA. Evening shift - the unit was staffed with one (1) BHA and per facility guidelines they should have had two (2) BHA's. The shift was short staffed one (1) BHA.

4. In interview on 04/04/2025 at approximately 12:34 pm with patient care staff member B # 4 (BHA), confirmed . we (BHA's) are always short staffed.

5. In interview on 04/04/2025 at approximately 3:40 pm with patient care staff member B # 6 (BHA), confirmed lot of people have been fired or resigned and we are short on nights.

6. In interview on 04/07/2025 at approximately 12:20 am with administrative staff member A # 5 (Human Resource Director), confirmed that H # 2 has been short staffed.

7. In interview on 04/07/2025 at approximately 2:44 pm with nursing staff member D # 3 (New Interim Director of Nursing-DON), confirmed the units have been short staffed. We need to hold admissions.

8. In interview on 04/07/2025 at approximately 3:07 pm with administrative staff member A # 1 (Chief Executive Officer-CEO), confirmed the facility has had a lot of staff call-offs, which leaves the patient care units short staffed.

Based on document review and interview, the nurse failed to ensure a weekly skin assessment was completed in six (6) instances. (Patient # 10)

Findings include:

1. The facility policy titled, Skin Assessment, PolicyStat ID: 12385990, indicated on page one (1) - Procedure - Assessment - number one (1) skin assessments should be completed one (1) time per week. This policy was last revised on 09/2022.

2. Review of the closed medical record for patient # 10 indicated the patient was a 20 year old admitted to the inpatient unit on 01/27/2025 with a diagnoses which included, but were not limited to, major depressive disorder, severe without psychotic features, suicidal ideation, and attention deficit hyperactivity disorder (ADHD). Weekly Skin Assessment form dated 01/27/2025 indicated the patient had bruising on his/her left forearm and blisters to the bottom of both feet. The form lacked a patient skin assessment on 02/04/2025, 02/11/2025, 02/18/2025, 02/26/2025, 03/04/2025, and 03/11/2025.

3. In interview on 04/07/2025 at approximately 2:44 pm with nursing staff member D # 3 (Interim Director of Nursing), confirmed nurses should be completing weekly skin assessments every Tuesday on the Skin Assessment Form.