HospitalInspections.org

Based on medical record review, policy review, incident report review, Idaho Code review, and staff interview, it was determined the facility failed to ensure patients were free from all forms of abuse and harassment for 1 of 2 BHU patients (Patient #10) whose records were reviewed. This put patients at risk of further abuse and had the potential to affect all patients receiving care in the facility. Findings include:

"IDAHO STATUTES TITLE 39 HEALTH AND SAFETY CHAPTER 53 ADULT ABUSE, NEGLECT AND EXPLOITATION ACT," updated 7/01/18, stated, "Duty to report cases of abuse, neglect or exploitation of vulnerable adults. (1) Any physician, nurse, employee of a public or private health facility ... who has reasonable cause to believe that a vulnerable adult is being or has been abused, neglected or exploited shall immediately report such information to the commission." This statute was not followed.

A facility policy titled "Abuse-Neglect - Care of Adult Child or Vulnerable Adult," effective 1/10/20, defined "Abuse" as "the intentional or negligent infliction of physical pain, injury or mental injury." The policy defined "Vulnerable Adult" as "a person 18 years of age or older who is unable to protect him/herself from abuse, neglect or exploitation. The person exhibits physical or mental impairment, which affects the person's judgement or behavior to the extent that he lacks sufficient understanding or capacity to make or communicate or implement decisions regarding his person." The policy stated, "Portneuf staff report all suspected abuse ... of any persons to the appropriate authorities per legal statute," and, "Any hospital staff member with knowledge of abuse/neglect reports alleged abuse/neglect to Adult Protective Services within 24 hours." This policy was not followed. An example includes:

Patient #10's medical record was reviewed. Patient #10 was a 27 year old male admitted to the BHU on 10/26/22 for aggression and assaultive tendencies. Additionally, the record stated Patient #10 had a developmental disability.

Patient #10's record included a nursing note dated 10/29/22 which stated, "Pt upset about 15 min check at the beginning to the shift yelling and arguing with staff. Pt educated on shift behavior plan that his phone would be give [sic] back after he can be calm for 15 mins. Security called and pt continued to yell and argue with staff. Pt give [sic] ... medication and was able to maintain a calm demeanor to get phone back after about 45 mins."

A BHU incident report was provided for the incident between Patient #10 and the CN on 10/29/22. The incident report was dated 10/29/22 and signed by the Security Officer. It stated, "[Patient #10] threatened violence toward the staff. Officers ... responded to find the patient very agitated and the charge nurse asking the patient to surrender his cell phone as a consequence for his inappropriate actions. The patient refused to surrender his phone at which time the charge nurse asked security to restrain the patients [sic] arms so the phone could be collected."

Grievances from the BHU were provided. There was a grievance dated 10/31/22 from Patient #10's legal guardian with the complaint category listed as "abuse or neglect." The grievance investigation stated, "call from [name] who wanted to report a verbal abuse of her son who was on the behavior health unit and file a formal grievance. [Name] report that she was on a video call with [Patient #10] on Saturday evening around 7 pm and heard a staff member verbally abusing [Patient #10]. She stated she heard the man yelling at [Patient #10] and dropping the F-bomb."

Grievance investigation notes for the incident with the CN and Patient #10 were provided. The interview with the CN stated, "[CN name] said he did yell at [Patient #10] and may or may not have used profanity. When asked if [CN name] remembers if he may have used vulgar language like the F-bomb, [CN] reported that he might have swore but does not remember using the F-bomb."

On a document titled, "Investigation notes for [CN name]," it stated prior to 11/11/22, the Director of Risk Management made the CNO aware that the grievance of alleged verbal abuse was completed and that it was officially turned over to nursing leadership for follow up and corrective actions."

The investigation notes for the CN stated on 11/14/22 he was placed on administrative investigatory suspension, 14 days after the grievance alleging verbal abuse was received.

The Security Officer involved in the incident was interviewed on 11/15/22 beginning at 10:43 AM. He stated, "language was spoken toward [Patient #10]," and, "the charge nurse basically called [Patient #10] stupid," and, "it was basically like bullying." When asked if he considered the incident verbal abuse, the Security Officer stated, "yes one hundred percent."

The CN's as worked schedule was reviewed. It showed the CN worked 2 shifts after the facility was made aware of the alleged verbal abuse on 10/31/22. The CN worked shifts on 11/01/22 and 11/13/22.

The CNO was interviewed on 11/15/22 beginning at 1:30 PM, along with other hospital staff. When asked if the CN who was being investigated for verbal abuse continued working through the investigation, after the facility became aware of the alleged abuse, he stated, "I believe he has put in a shift or 2 after the incident."

The VP of Quality was interviewed on 11/17/22 beginning at 9:30 AM. When asked if the incident regarding the verbal abuse was reported to APS, he stated it was not.

The facility failed maintain patients' right to remain free of all forms of abuse and harassment.