HospitalInspections.org

Based on document review and interview, the facility failed to provide a care setting free from physical, verbal, mental, or emotional abuse by facility staff members, and failed to report a registered nurse to the appropriate licensing agency after confirmed patient abuse in 1 of 10 medical records reviewed. (P1)


Findings include:


1. Facility policy titled," Patient Rights", PolicyStat ID 17199060, last revised 1/2023, indicated under PROCEDURE: Patient Rights: 1. The following rights shall be afforded to all patients and are not subject to modification: g. Patients have the right to be protected by the Hospital from neglect; from physical, verbal and emotional abuse (including corporal punishment); and free from all forms of misappropriation and/or exploitation.

2. Facility policy titled,"Abuse and Neglect", PolicyStat ID 17197681, last revised 01/2023, indicated under PROCEDURE: 9. Follow-up. b. If the allegation of abuse against staff is substantiated through a thorough and complete investigation, the staff member shall be terminated and reported to the appropriate licensing board, and regulatory agencies as applicable.

3. Review of P1's MR (Medical Record) indicated provider note documentation dated 8/26/25 at 10:15 am by NP1 (Nurse Practitioner) indicated P1 became upset because during group T1 called him/her a disease, a sickness, and was never going to heal. 1:1 observation was continued.

4. Corrective action documentation dated 9/3/25 indicated N1 (Registered Nurse) was terminated related to the following violations: On 8/25/25 N1 displayed unprofessional behaviors with P1's appointed guardian/government caseworker on the phone while discussing P1's care. Additionally, while P1 was speaking to his/her appointed guardian/ government caseworker on the phone, N1 exhibited verbally abusing statements towards P1 prohibiting P1 from speaking freely with their appointed guardian/ government caseworker as well as threatening P1's phone privileges to speak to his/her appointed guardian/ government caseworker would be revoked. On 8/26/25 staff witnessed N1 threaten P1 with a restraint if P1 did not comply with the nurse's direction. P1 was placed in a physical restraint by N1 and BHT1 (Behavioral Health Technician), during the restraint N1 was witnessed covering P1's mouth while restraining the patient restricting his/her breathing.

5. In interview on 9/24/25 at approximately 10:15 am with C1 (Complainant) confirmed P1 stated, "T1 (therapist) called me a disease." C1 confirmed T1 having access to P1 post incident, T1 and P1 had an incident over T1 not giving P1 a sucker. That encounter resulted in a code purple d/t (due/to) T1 triggering P1. C1 confirmed in his/her opinion that T1 psychologically abused P1 twice triggering P1's aggression.

6. In interview on 9/25/25 at approximately 9:45 am with BHA1 (Behavioral Health Associate) confirmed during the physical hold on 8/26/25 at approximately 10:00 am the associate heard T1 state," Look at that dumb shit." referring to the way P1 was behaving. BHA1 also confirmed N1 placed his/her and over P1's mouth during the physical restraint on 8/26/25.

7. In interview on 9/25/25 at approximately 10:00 am with BHA2 (Behavioral Health Associate) confirmed on 8/26/25 during physical restraint, P1 was yelling, P1 voiced T1 said that P1 was a disease and would not get better, T1 agreed he/she said P1 was a disease and would not get better. P1 was upset about the comments. N1 directed the correction towards only P1, yelled at P1. P1 had previously spit on N1. N1 confirmed the reason why he/she was singling out P1 for discipline over other patients. In a previous hold P1 spit in T1's face twice. T1 took time off after spitting incident and when T1 returned to work on 8/26/25, T1 made the comments about/toward P1.

8. In interview on 9/25/25 at 12:30 with A1 (Chief Executive Officer) confirmed N1 was not reported to the appropriate licensing agency immediately after substantiated abuse but should have been.