Nurse Covering 18 Patients Said She Was Unable to Intervene to Stop Abuse

Old Vineyard was found by the Centers for Medicare and Medicaid Services to have failed to ensure the protection of patients’ right to be free from abuse. The violations relate to an incident in which a 250-pound staff member forced a 65-pound 12-year-old boy to the floor, pinned him down with his knee and pressed on his head with his hand. Nurses heard the employee curse at the patient as he forcibly escorted him to the seclusion room and then blocked the doorway. One nurse said that she was not able to intervene to protect the child in the above incident because, “I am rarely able to leave our glass bubble (nursing station). We have 18 patients with one nurse. (RN #2) stayed over but she said she wasn’t helping with the new admissions until her day shift charting was done. I had four admissions.”

Another patient, a 13-year-old girl, was placed in a physical restraint for 5 minutes followed by mechanical restraint for one hour and seclusion for one hour because she had been banging her head on the wall. Her medical record revealed that she became calm 30 minutes after the intervention began, which should have indicated release from the restraint and seclusion. However, the patient was kept in restraint and seclusion for 55 minutes after becoming calm.

CMS found that Old Vineyard had placed patients in immediate jeopardy and notified the facility that its participation in Medicare and Medicaid would be terminated if deficiencies were not corrected. CMS accepted Old Vineyard’s plan of correction, which included revising facility policies, retraining direct care staff and increased monitoring by administration.