LINCOLN — State officials are investigating an incident at the Lincoln Regional Center that left a patient with a 3-inch bruise on his hip and resulted in the suspension of three employees.
One of the suspended workers caused the injury, one failed to report it to authorities and the third was suspended for talking about the incident in an “inappropriate way” with other staff members.
State health inspectors imposed a sanction on the state-run psychiatric hospital because of the nearly two-week delay in reporting the incident. The inspectors found that the failure to report put patients in “imminent danger.”
The sanction began around midday Tuesday and was lifted Thursday morning.
Scot Adams, behavioral health director for the Nebraska Department of Health and Human Services, called the episode “embarrassing.”
“We have over 500 staff members, and I think we had one who lost his cool,” Adams said. “Patient safety is the highest concern at the Lincoln Regional Center.”
The incident occurred May 14 in a unit of the security building. That building houses patients found not responsible for crimes by reason of insanity and mentally ill patients who cannot be managed elsewhere because of their behavior.
Adams said the injury resulted because an employee didn't follow proper methods to calm a patient.
Regional center employees are trained in Mandt methods of resolving conflicts and de-escalating violent or potentially violent situations. The Mandt system was developed in 1975 for the Austin (Texas) State Hospital and now is used around the world.
HHS spokeswoman Kathie Osterman said the incident didn't come to light until May 27, when staff members became concerned by a patient's comment.
The comment was made when members of the hospital's quality assurance staff were doing routine records reviews, she said.
The reviews revealed discrepancies in the documentation of the event. Adams said the records didn't match what security recordings show.
A preliminary investigation led to regional center officials suspending the employee and reporting the incident to Adult Protective Services, as required by state and federal regulations. The second employee was suspended June 11 because of the documentation issues and failure to report the incident, Osterman said. The third worker was suspended Friday.
Adams said department officials still are investigating the situation.
“We are taking this very seriously, but I do not see this as a systemic indication of anything,” Adams said.
The imminent-danger sanction was the first substantiated complaint in nearly five years, he said. To have the sanction lifted, the regional center had to show it could ensure patient health and safety, Osterman said.
All employees will receive refresher training about abuse and neglect policies and about Mandt methods.
About 400 employees had gone through the 20-minute training as of midday Friday and all others will be trained before they start their next shift, she said.
State inspectors have 20 working days to write up their findings, after which the regional center must develop a plan for correcting any violations of patient care standards.
The 250-bed regional center provides treatment for sex offenders and for those judged mentally ill and dangerous to themselves or others. Patients are committed by local mental health boards or by the courts.