AdventHealth patient 'didn't like to be held down.' Request for help ignored: CMS report
A 17-year-old in a mental health crisis requested that the staff at AdventHealth in Hendersonville connect them to a patient advocate because they “’didn’t like to be held down.’” Despite the patient's pleas, documentation that they made the request and the patient advocate’s business card sitting at the charge nurse’s desk, AdventHealth’s patient experience team was not notified of the patient’s request.
The account was detailed in an unredacted inspection report compiled by the federal Center for Medicare and Medicaid Services and the North Carolina Department of Health and Human Services and obtained by the Citizen Times from CMS. The Citizen Times initially reported the redacted citation Aug. 9.
According to a Nov. 9, 2022 provider note, the patient had attempted multiple forms of self-harm and had been a victim of physical and sexual assault at different facilities. The note said, according to the inspection report, “the patient is voluntary at this time. If (the patient) does try to leave, we will involuntarily commit (them). When I discussed this with (the patient, they) wanted to be cooperative.” The patient’s identity is not disclosed in the inspection report. The Citizen Times is not revealing the patient's gender since they were a minor at the time of the incident.
A provider note from the following day indicates the patient was involuntarily committed.
Based on a Nov. 12, 2022 provider note, the patient became violent with staff, who then gave the patient a sedative and antipsychotic medication. The same note indicated that following the medication “patient was eventually put back in (their) room and became cooperative.”
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Less than an hour later, a note from a nurse revealed that the patient requested to speak to a patient advocate. The nurse who wrote the note passed on the request to the charge nurse and house supervisor. The next day, the patient was transferred to a different hospital.
Investigators spoke to a registered nurse as part of the inspection. The nurse recalled that the patient had assaulted staff and police had to be involved. She also noted that the patient advocate’s business card was at the charge nurse’s desk. The nurse did not recall if she or the patient spoke to a patient advocate.
Investigators then spoke to someone on the patient experience team who went through their notes and could not find anything to indicate that anyone had asked her to speak to the patient.
In a follow-up interview, the same nurse revealed that she spoke to the patient who revealed to her that they wanted to speak to the patient experience team because the patient “’didn’t like to be held down.’” During this interview, the nurse admitted that she “didn’t call patient experience.”
In an Aug. 16 statement to the Citizen Times, AdventHealth spokesperson Victoria Dunkle said, “We do not comment on personnel issues.”
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Regulators specifically cited AdventHealth for failing to “establish a process for prompt resolution for patient grievances.” They also said the hospital “must inform each patient whom to contact to file a grievance.”
To address the concerns outlined by regulators, AdventHealth proposed revamping its patient complaint and resolution policy in their plan of corrections. This included re-educating their employees, creating procedures for educating new employees and hanging posters in every patient room in specific sections of the hospital that list the contact information for department leaders. Dunkle reiterated these initiatives in her statement to the Citizen Times.
Mitchell Black covers Buncombe County and healthcare for the Citizen Times. Email him at mblack@citizentimes.com or follow him on Twitter @MitchABlack. Please help support local journalism with a subscription to the Citizen Times.
This article originally appeared on Asheville Citizen Times: AdventHealth patient's request for advocate unfulfilled report says
