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Occurrence Summary Reports for:
Saturday, May 26, 2018 7:15 PM

Date of Occurrence: 2/5/2017
Report Timely: Yes
Type of Occurrence: Neglect

On 2/5/17 there was an allegation of staff neglect towards a female patient, who was in her 30s.

The facility conducted an internal investigation and notified the police. Per the patient's plan of care, she required two-to-one (2:1) staff monitoring which would include staff remaining within an arm's length of the patient and maintaining a full view of the patient's hands at all times. The patient had a history of self-harm, in particular stuffing foreign objects into her wounds. Staff provided monitoring in the day room after searching the area for any harmful objects. The patient alleged two-pool staff members and one security staff member were talking about sexually inappropriate things in front of her. The patient alleged one of the staff members motioned to his private parts and shook his keys at her. She stated she asked the staff member what he meant by shaking his keys at her and she reported the staff member stated, "You don't want to know." The patient reported she felt unsafe, and as a result of hearing this information, she wanted to hurt herself. The patient inserted pieces of an apple into her existing arm wound. The patient reported the staff members did not even see her do this because they were busy talking. The staff members were placed on administrative leave. Nursing assessed the patient's wound, cleansed the wound and redressed the wound. The nurse reported there were no apple pieces inside the wound, but pieces fell out of the dressing as the nurse removed the wrapping. Two days later, the medical provider noted mild cellulitis in the wound and anti-biotics were started. On 2/13/17, the patient was seen in the surgical clinic and staff found and removed two pieces of apple from inside the wound. It appeared the patient had been successful in placing the apple pieces in her wound and the patient had received an apple with her lunch. All three staff members denied talking inappropriately in front of the patient and denied being distracted from monitoring the patient during this time period. No staff witnessed the patient inserting the objects into the wound, but several staff reported they had to re-direct her from touching the bandage or wound during the day. Staff would continue providing 2:1 monitoring due to her on-going focus to engage in self-harm behaviors. From review of the information, the investigator was unable to determine when the patient inserted apples into her wound/dressing, but it occurred sometime between the mornings and evening dressing change. The appointing authority did determine the two staff members had discussed personal matters in front of the patient and this caused the patient to feel unsafe. This was a violation of professional boundaries which compromised the therapeutic relationship. Although it could not be determined if the patient was able to insert the apples into her wound/dressing while these two staff members were providing oversight, at some point between the mornings and evening dressing change, she was able to place apple pieces into the wound/dressing. Staff was to provide 2:1 monitoring of the patient. Staff were re-trained on policies and oversight expectations.

The Department reviewed the facility's report and supplemental documentation and found that the facility acted appropriately by reporting the occurrence, notifying the appropriate persons/agencies and conducting an investigation. The summary findings were based on facility information provided to the department at the time of review.

The Department will review this occurrence prior to the next survey.

Sent to Facility: 4/11/2017

FACILITY COMMENT: Following receipt of the above summary, no additional comments were submitted by the facility.

Released to Public: 4/26/2017