HospitalInspections.org

Based on review of documents, and interview with staff (EMP), it was determined that the hospital failed to adequately train staff on event reporting, and develop policies and procedures related to the investigation of allegations of abuse and neglect to include methods to protect patients from abuse during the investigation.

Findings:

Review of facility document "Adverse Events, Early Disclosure" effective June 26, 2023, reads in part: "... Procedure: 1. When an unanticipated outcome or untoward event is discovered, the primary focus and first priority is the protection of the patient from further harm by providing necessary medical care and reducing the likelihood of further injury. 2. Review the adverse event as soon as possible with appropriate members of the healthcare team once the patient's needs have been met, to collect information and determine next steps...." This document revealed no evidence that reporting adverse events is only "encouraged" and "voluntary" and not required. This document revealed no evidence of policies and procedures related to: injuries of unknown origin as indicators of potential abuse or neglect; and the investigation of allegations of abuse and neglect to include methods to protect patients from abuse during the investigation.

Review of facility document "Safety Event Reporting" effective June 25, 2024, reads in part: "... Event reports are used to identify significant events requiring further analysis, to assist in the development of corrective actions to resolve the root cause(s) of problems identified, and for trending analytics.... Policy. A. Potential safety concerns, including precursor events, near misses, and errors are entered into the online safety event reporting system regardless of injury/harm to the patient. B. Enter a safety event report as soon as possible, usually within the shift of occurrence and preferably within 24 hours. Prompt reporting of errors/events and near misses must occur in order to enable timely identification and resolution of system issues and promote performance improvement...." This document revealed no evidence that reporting adverse events is only "encouraged" and "voluntary" and not required. This document revealed no evidence of policies and procedures related to: injuries of unknown origin as indicators of potential abuse or neglect; and the investigation of allegations of abuse and neglect to include methods to protect patients from abuse during the investigation.

Review of facility document "Abuse/Neglect/Exploitation Reporting for Children and Adults" effective December 4, 2021, revealed no evidence of policies and procedures related to: injuries of unknown origin as indicators of potential abuse or neglect; and the investigation of allegations of abuse and neglect to include methods to protect patients from abuse during the investigation.

Interview on August 4, 2025, at 11:17 AM, EMP13 indicated that if a nurse received and assessed a patient with a new bruise, cut, or injury that was not documented previously, and the nurse had no knowledge of how the bruise, cut, or injury originated, the nurse would notify the clinical team. The clinical team or wound care team may try to determine the cause of the injury. It may or may not get reported in the event reporting system.

Interview on August 5, 2025, at approximately 10:01 AM, during review of the facility's event reporting log from January 1, 2025, through August 5, 2025, EMP33 indicated that staff reporting of events is "encouraged" and "voluntary" and not required. EMP33 indicated that only reported events are reviewed and investigated.

Interview on August 5, 2025, at approximately 11:36 AM, EMP36 indicated that if a nurse identifies an injury or bruise of unexplained origin, the nurse will document it in an assessment, ensure the provider is aware, and consult wound care or others as appropriate. EMP36 indicated that an injury of unknown origin would only be entered into the facility's event reporting system and investigated if the cause was observed by staff.

Interview on August 5, 2025, at approximately 11:45 AM, EMP3 also indicated that an injury of unknown origin would only be entered into the facility's event reporting system and investigated if the cause was observed by staff. At 12:41 PM, EMP33 indicated that the facility would consider ruling out suspicion of abuse after a reported event was reviewed, and the facility's investigation identified that an individual did not follow the standard of practice. If the individual was a provider, they would be evaluated by the peer review process. If the individual was a nurse or other employee, it would be handled by the leadership for that person and human resources, utilizing the performance management process.

Interview on August 5, 2025, at 12:41 PM, EMP3 indicated that if EMP3 observed an employee abusing a patient, EMP3 would notify the supervisor and human resources, and possibly the chief medical officer. Interview at 1:25 PM, EMP33 provided the surveyor with the facility documents related to the peer review process for providers and the "Performance Management Decision Tree" that would be followed for employees related to suspicion or allegations of abuse. These documents revealed no evidence of policies and procedures related to the investigation of allegations of abuse and neglect to include methods to protect patients from abuse during the investigation.