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SPRING GROVE HOSPITAL CENTER 55 WADE AVENUE CATONSVILLE, MD 21228 Sept. 18, 2014
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on an onsite investigation inclusive of interviews, policy and procedure, patient records and other documentation, it is revealed that 1) Staff failed to consistently implement physician ordered self protection orders for patient #1 resulting in this patient sustaining injuries; 2) Staff failed to follow protocols for notification of nursing staff and facility required staffing levels when allowing the patients to go outdoors to the courtyard; 3) Staff failed to inform the RN of patient #1's injuries and failed to document the injury until otherwise noted by the LPN; 4) Staff failed to accurately record rounds documentation; and 5) The hospital failed to complete the federal fingerprint check for the DCA#1 for one year after her employment.


Patient #1 is an adolescent male admitted approximately mid-August 2014. When interviewed by the surveyor on 9/16 at approximately 10:30 am, patient #1's psychiatrist stated that patient #1 was physically threatened by two other patients #3 and #4. Despite Patient #1 already being on close observation (CO) and elopement precautions (EP) since admission, the psychiatrist wrote orders for Self Protection. As explained by the psychiatrist, Self Protection orders mean that when the patient is in the day room, staff are to be in the dayroom, and staff are required to monitor the hallways for Patient #1's safety. Further, patients #2 and #3 were to remain at least 10 ft away from patient #1 at all times. The physician order also stated that "Pt is afraid of (patients #2 and #3). Do not leave the dayroom alone when pt is with the others. Monitor the children at all times."


On 9/13 during the day shift, it was noted by the day RN that there was arguing back and forth between patient #1 and patient #3, and that patients #2 and #3 were talking in their native tongue (Spanish) to one another in a secretive way about patient #1. The RN stated that the main aggressor appeared to be patient #3 who was asked to take a time-out in his room. During that time-out, the RN moved patient #1 to a room closer to the nursing station. At the end of his shift, the room change and his concerns were reported to the oncoming shift and documented the same.


Patient #1 reports that on the evening of 9/13 while he watched a movie in the day room, there was no staff present when patient #2 smashed a peanut butter and jelly sandwich into the right side of the head of Patient #1. When patient #1 asked patient #2 why he had done that, patient #2 started to physically hit patient #1 (demonstrating around waist level punches). Patient #1 denied being physically harmed during the altercation. He states the assault stopped when a staff member entered the previously unoccupied nursing station which is adjacent to the day room and affords nursing a clear view of the dayroom. Patient #1 states he did not inform staff of the incident due to fear of reprisal. Instead, he walked to his room where he showered and washed off the rest of the sandwich from his hair.


That same evening, Direct Care Assistant #1(DCA #1) documented at 10:30 PM that patient #1 had been hanging by his bedroom door" with the peers he accused of bullying him (patient #2 and #3)." She documented that "He ( Patient #1 )was redirected to be quiet and close his door, but pt refused to listen and continued to play at his door with his peers without a shirt on." Based on this note, it appears that patient #1 was where he was supposed to be (at his room), but that the other two patients were not. There was no documented evidence that the DCA redirected patients #2 and #3 from patient #1's door as required by the self protection order of 9/9/2014.


On 9/14, patient #1 reported being in the dayroom when DCA #1 who was assigned to watch the patients in the dayroom, left to "Get the snacks." When the DCA left the day room unsupervised, it left patient #1 alone with the rest of the patients, which was confirmed by the surveyor during interviews on 9/18 at approximately 3:30 PM with both patient #1 and DCA #1. DCA #1 stated she had left the day room to get the snacks.


On both these occasions 9/13 and 9/14, the absence of a staff member in the day room allowed patient #2 to initiate aggressive actions toward patient #1. Leaving patient #1 alone in the day room with peers was in direct conflict to the psychiatrist order that patient #1 not to be in the dayroom alone with the other patients. Further, as documented, staff failed to direct patient #3 to leave patient #1's door so there would be a 10 foot distance maintained between patients #1 and patient #3.


It is also reported that on 9/14, patient #1 was assaulted by patient #2. According to the note by DCA #1, she reported that patient #1 incurred an injury when she took the patients outside to play basketball. The DCA wrote at 8:30 PM. that "Around 5-5:30 PM staff took the kids out for fresh air. The boy pts were playing basketball. All of the kids jumped at the same time and the pt was elbowed. I asked him if he was okay and if he wanted to see the nurse. He said he was fine and refused to see the nurse or get an ice pack. During bed time, I did notice a lump on the side of his head. The Charge nurse was informed."



During an interview with the activity therapist on 9/16 at approximately 11:30 am, the surveyor determined that the facility protocol requires two staff to take patients outside due to safety reasons, and that the staff must inform the RN prior to doing so. Based on the surveyor interview of DCA #1 on 9/18 at approximately 3:30 she stated that she informed the RN that she was taking the patients outside by herself. However, this was refuted by the RN who was interviewed by the surveyor at 3 PM of the same day. Therefore, if the DCA did take the patients out as she alleges, she did so by herself, and without the knowledge of the Charge RN. Further, if the DCA took the children out to play basketball, she did so without following the self protection order of 9/9 since patient #1 and patients #3 and #4 were all reported as having played basketball.


When interviewed, Patient #1 described in detail the events on 9/14 which precipitated his injuries. The DCA's documentation of the incident is not consistent with the information provided by Patient #1. Due to fears of retaliation, patient #1, at first, agreed to state that his injuries occurred as part of a basketball accident (being elbowed). That story was fabricated according to patient #1 by the DCA #1 following three assaults by patient #2 in the day room which left patient #1 with obvious facial injuries. Patient #1 stated that DCA #1 witnessed two the three assaults that had occurred in the dayroom and made no attempt to intervene.


Patient #1's account is that patient #2 approached him three times to fight, and though patient #1 states he refused, patient #2 stated to patient #1 that he would hit him anyway, so he better fight. Patient #1 described each assaultive interaction in great detail where patient #2 was punching at his face during these three episodes lasting approximately two minutes each. He was unsure of the time of the assaults but stated he believed them to occur on or around 6:30 to 6:50 PM.


Rounds documentation for each ? hour for Sunday 9/14/14 was reviewed by the surveyor and it was noted that patient #1 was on the phone at 5 PM, then in the day room for each ? hour check through 8:30 PM. Rounds documentation for patient #2 on the same form reveals that he was on the phone at 5:30 PM, and in the Dayroom through 8:30 PM. According to the activity schedule, there was a possible "Fresh air break" at 5:15 PM where the patients might go outside, and then dinner at 5:50 PM. There is no evidence on two rounds boards that any of the patients were taken outside, only that the patients largely remained in the dayroom consistent with patient #1's statement.


Patient #1 states that following the three assaults, his peers noted his cheek was swollen, and one patient posed the question of how his injuries could be explained to staff. Patient #1 stated that DCA #1 told the patients to lie stating "We can say that we went outside for basketball, and that you got elbowed in the face." No matter the manner of injury, DCA #1 was obligated to report all patient injuries to the RN. This was not done. The DCA note of 8:30 PM that states the RN was made aware of the injuries, however this was only done subsequent to the LPN discovering the swelling to patient #1's face. It was not until that time that DCA #1 documented anything related to the injury of patient #1.


Observation on 9/16 of patient #1's injuries revealed a healing right black eye with bruising above and below the eye, a healing bruise above the left eye and brow-bone with a central healing linear cut or abrasion, a 2 cm bruise in the center of the left cheekbone, and a faint shadow of a bruise on his right cheekbone that Patient #1 stated was initially swollen.


Review of DCA #1's employee record by the surveyor revealed that there was documentation of federal background check being done but the results of the check were not in the file. Documentation of a federal background check. was eventually located by staff with a received date of 9/23/2014. Therefore, while DCA #1 had been employed for greater than one year, no Federal background check had been received by the hospital for nearly a year.

In summary, the investigation reveals that patient #1 was provided with care in a safe setting as indicated by:

1) Patient #1 suffered injuries during a time when he was known to have been threatened and bullied by various peers, and was under orders for self protection, including a restriction to keep specific patient more than 10 feet away at all times.

2) Patient #1's facial bruising was significant and not localized to one area similar to an elbowing incident. There is no indication that clinical staff questioned if the injuries were consistent with the DCA report of being elbowed while playing basketball. Further if in fact the DCA took the patient's out to play basketball it was done without the RN's knowledge and approval and without two staff as required for safety purposes. There is no indication that clinical staff questioned the causative nature of the injuries despite the fact that the patient had significant facial bruising.

3) Rounds documentation is not consistent with the DCA #1's report of going outside to play basketball.

4) DCA #1 failed to report or document patient #1's facial injuries to the RN until hours later and only after the injuries were observed by the LPN

5) A federal fingerprint background check was not completed for DCA#1 until one year after employment.