Go to the State of Colorado Web
Occurrence Summary Reports for:
Friday, June 22, 2018 10:26 PM

Date of Occurrence: 4/8/2017
Report Timely: Yes
Type of Occurrence: Abuse/Verbal

On 4/8/17 a male patient, in his 60's, reported that a staff member threatened to beat him up.

The facility conducted an internal investigation and notified the police. The patient, who has a diagnosis of schizophrenia, was upset and stated that a female staff member (#1) was threatening to beat him up. The patient reported that staff member #1 said the word “chingas” in Spanish, which he stated means beating. Staff member #1 was removed from the unit and placed on administrative leave pending the facility's investigation. The patient was interviewed on the day that he reported the allegation and then was interviewed again on 4/10/17. The patient stated “She didn't like the way I was looking at her so she said chingas.” The patient reported that he was angry and paranoid but later stated he felt safe on the unit. The facility interviewed five other staff members. One staff member (#2) witnessed the conversation between the patient and staff member #1. Staff member #2 reported that the patient told staff member #1 that he had taken his medication and was feeling better and that it appeared that the patient was seeking acknowledgement for taking his medication. Staff member #2 reported that staff member #1 responded by telling the patient that was good and playfully said she would give him “chingas” if he acted out again and made a gesture like spanking. Staff member #2 observed the patient respond by smiling and stating “I know what that means” and returning to his room. The patient was later observed pacing in the hall in an angry and aggressive manner and saying that he wasn't going to let anyone beat him up. The patient then approached staff member #1 and threatened to physically harm her. Staff member #1 left the unit at that time to allow the patient to calm down. Staff member #1 was interviewed regarding the patient's allegation. Staff member #1 reported that the patient had said to her “Just give me chingas if I act out again.” Staff member #1 reported that she was repeating what he said to her and that her comments were intended to be playful. Staff member #1 denied being threatening and believed that “chingas” meant spanking. The facility conducted background and reference checks on staff member #1 at the time of hire and staff member #1 had not been involved in any other allegations of abuse. The facility concluded that staff member #1 acted unprofessionally and that the interaction between her and the patient was non-therapeutic and the communication was inappropriate. However, the facility was unable to substantiate abuse. Staff member #1 returned to work on 4/28/17 with increased supervision for performance management. Staff member #1 was required to review and discuss the facility's code of conduct and adult patient abuse and neglect policies as well as attend various trainings including customer service fundamentals and confrontation/conflict, code of conduct, self-awareness, interpersonal skills, professional ethics and boundaries and patient safety, abuse and neglect. Staff member #1 was provided educational literature to assist with daily interactions with patients and understanding schizophrenia.

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: 5/30/2017

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

Released to Public: 6/9/2017