The Florida Agency for Health Care Administration (AHCA) cited Manatee Palms Youth Services because it failed to comprehensively implement its policy of reporting and investigating alleged patient abuse, neglect, and exploitation in two separate incidents involving the same staff member (Staff Member A). In one incident, a patient alleged that Staff Member A had choked him during an altercation. Despite the serious nature of the alleged incident, there was no documentation in the patient’s clinical chart about the allegation. A second staff member (Staff Member B) completed a facility event report regarding the altercation and had documented the presence of “red marks” on the patient’s neck, but there was no indication that the patient was assessed by anyone following the incident other than Staff Member A, who allegedly choked the patient.
Another patient alleged physical abuse by Staff Member A during a restraint incident. The patient was observed (on video surveillance) to be aggressively approaching Staff Member A, who then caught the patient with his arm around her neck and slammed her face to the floor.The facility’s Risk Manager stated in an interview that she only became aware of the event when another agency came to the facility to investigate the allegation. Interviews with the Human Resource Director further revealed that she was unaware of any allegation of abuse involving Staff Member A and that as of the survey inspection date, Staff Member A had not been suspended at any point, “even though the facility had documented 2 events that involved allegations of abuse to clients by the staff member.” AHCA also determined that the facility failed to implement protection measures for the alleged victims.There was no indication in either incident that Staff Member A was removed or separated from the alleged victims following these incidents.
AHCA also cited the facility for failing to implement a risk management program for three patients by not properly documenting adverse incidents, not assessing patients for injury and not implementing proactive measures to protect patients involved in adverse incidents. AHCA found that failing to have a risk management process can “place residents at risk for non-receipt of services and potentiate a system failure in regards to minimizing risk for clients.”