HospitalInspections.org

Based on observation, record review, and interview, the hospital failed to meet the Conditions of Participation of Patient Rights. This deficient practice was evidenced by the hospital 1) failing to ensure that each patient has the right to be free from all forms of abuse or harassment as evidenced by the hospital failing to identify physical abuse that occurred for one sampled adolescent patient by a staff member (Patient #3) and 2) failing to ensure a complaint by a family member regarding alleged staff to patient physical abuse was recognized as a grievance for 1 (Patient #3) of 5 sampled patients reviewed for complaints/grievances (See findings at Tags A0118 and A0145).

Based on observation, record review, and interview the hospital failed to ensure that each patient has the right to be free from all forms of abuse or harassment as evidenced by the hospital failing to identify physical abuse that occurred for one sampled adolescent patient by a staff member (Patient #3).
Findings:

Review of the hospital policy titled, Abuse and Neglect Assessment (PE.032A, effective 08/2024) revealed in part that child physical abuse is defined as an injury, unreasonable confinement, intimidation or cruel punishment of a child resulting in physical harm or death.

Review of an LDH Abuse/Neglect Self Report (Final) dated 03/12/2025 revealed an incident that occurred on 03/11/2025 at 12:50 PM between S2BHT and Patient #3. This report revealed the following timeline of events:
12:58 PM - Patient and tech are sitting at the table and appear to be having an appropriate conversation
12:59 PM - The patient suddenly stood up and approached the tech while he was still sitting as if he was about to attack the tech. The tech went hands on pushing the patient away. The patient and tech struggle and the tech pushes the patient into room 208.
1:00:04 PM - The tech and patient appear to separate, but this is unclear due to camera view
1:00:34 PM - The tech exits the room
1:00:34 PM - The tech is standing at bedroom door
1:00:41 PM - The tech closes the door
1:00:48 PM - Tech in day room, looks at right hand as code green team arrives.
1:02 PM - The patient exits room with staff, noted holding paper to his nose. The patient was placed in seclusion and then nose assessed by House Supervisor.

The Self Report further revealed that Patient #3 was interviewed by the Patient Advocate on 03/11/2025 and the patient stated that S2BHT punched him in the nose with his fist.

Under Investigation Results on the Self Report, it stated that the hospital was unable to substantiate the allegation due to a lack of evidence. Video surveillance was reviewed and revealed the tech "go hands on" and push the patient, however due to lack of surveillance in the room we were were not able to corroborate the patient's allegation of being hit in the nose. The patient was noted to have a nosebleed, however we are not able to state the cause of this. The staff was placed on administrative leave 03/11/2025 and cannot return until CPI and verbal de-escalation is complete.

On 04/07/2025 at 1:20 PM, the survey team viewed the video of the incident dated 03/11/2025 involving Patient #3 and S2BHT with S3Risk Manager. The video revealed that S2BHT and Patient #3 were sitting at a table in the dayroom when Patient #3 suddenly stood up and pulled up his pants. At that time, S2BHT stood up and forcefully pushed Patient #3 in the chest, pushing the patient across the floor. The tech then pushed the patient a second time until the patient was eventually forcefully pushed so much that he was pushed into his bedroom (which was adjacent to the day room). At no time was the patient observed to put his hands on the tech. The patient was not observed to be aggressive. There were no cameras in the patient's room, but approximately 30 seconds later, the tech walks out of the patient's room and pulls his right hand up as if examining his knuckles. One minute later, the code green team (that was called by the nurse to assist with aggressive patients) arrived on the unit. The patient was then observed to be led out of the seclusion room by staff. The patient was holding a bloody tissue to his nose. Observation revealed that as Patient #3 walked by S2BHT, S2BHT smiled/smirked at the patient. There was no audio sound to the video.

On 04/07/2025 at 1:40 PM, interview with S3Risk Manager revealed that she interviewed S2BHT on 3/11/2025 after the incident. She stated that when S2BHT was asked how Patient #3 sustained a bloody nose, he had no response. When asked if Patient #3 ever raised his hands to S2BHT, S3Risk Manager stated no. When asked if S2BHT used excessive force with Patient #3, S3Risk Manager stated yes. S3Risk Manager stated that S2BHT did not use proper CPI techniques. S3Risk Manager further stated that she asked S2BHT why he had a smirk on his face as Patient #3 walked by him as he was lead to the seclusion room, and S3BHT had no response.

On 04/08/2025 at 11:36 AM, interview with S2BHT (with S2Dir of QA and S3Risk Manager present in room) revealed that he was sitting at a table in the dayroom with Patient #3, when the patient suddenly stood up and came to him, "pulling his pants up like he was going to attack me and then he lunged at me". S2BHT stated that the patient grabbed him at his chest and then the tech pushed him off. S2BHT stated he was nervous about what the patient was going to do and when the patient came at him again, he pushed him off again to gain distance. S2BHT further stated that the pushing ended up in the patient's bedroom. S2BHT stated the patient kept trying to attack him, so he pushed the patient again and the patient hit the wall in the room. When asked if that was how the patient sustained a bloody nose, S2BHT stated "I guess".

On 04/08/2025 at 12:05 PM, interview with S2Dir of QA and S3Risk Manager confirmed that the interview the surveyor had with S2BHT did not match what happened on the video. They confirmed that the patient was not observed on video to lunge at the tech or lay hands on the tech. They confirmed that Patient #3 was not the aggressor. They further confirmed that S2BHT was suspended for six days and returned to the hospital to work with adult clients for 30 days, but will then return to work on the adolescent unit on 04/17/2025.