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The Condition of Participation: Quality Assessment and Performance Improvement Program (QAPI) was out of compliance.

Findings include:

Based on records reviewed and interviews, for one of 10 sampled patients (Patient #2), the Hospital failed to ensure the Quality Assessment and Improvement Program (QAPI) implemented and maintained an effective, ongoing, hospital-wide, data-driven quality assessment, and performance improvement program to implement preventative actions in response to a staff member reporting witnessing Nurse #1 physically abuse Patient #1, who sustained a skin tear.

Refer to TAG: A-0283.

Based on records reviewed and interviews, for one of 10 sampled patients (Patient #2), the Hospital failed to ensure the Quality Assessment and Improvement Program (QAPI) implemented and maintained an effective, ongoing, hospital-wide, data-driven quality assessment, and performance improvement program to implement preventative actions in response to a staff member reporting witnessing Nurse #1 physically abuse Patient #1, who sustained a skin tear.

Findings include:

Review of Patient #2's medical records, indicated that he/she fell at home, presented via emergency medical services to the Hospital, and admitted to the medical surgical unit in February 2023. During Patient #2's admission, it was determined that he/she was unable to make his/her own health care decisions due to cognitive impairment.

Review of the Hospital's Event Report, dated 3/6/23, indicated that on 2/19/23 (later identified the event occurred during the overnight shift beginning on 2/16/23), Patient #2 was confused, agitated, and kicking staff when a nurse alleged witnessing Nurse #1 grab Patient #2's hand and yelled, "Stop Kicking" and Nurse #1 proceeded to dig her fingernails into Patient #2's skin, drawing blood. Patient #2 stopped moving and yelled at Nurse #1, "Stop clawing me, that hurts." and Nurse #1 did not let go of Patient #2's hand. After Nurse #1 left Patient #2's room. The witnessing nurse assessed and attempted to dress Patient #2's injury. Patient #2 remained confused and agitated but the witnessing nurse redirected Patient #2 to stay in bed.

Review of the Employee and Labor Relations Investigation Summary, indicated at the end of March 2023, Employee and Labor Relations was informed of the allegation made on 3/6/23, regarding the allegation of staff abusing Patient #2. The Investigation Summary indicated that the investigation conducted by the Hospital was not completed. The report indicated that the Hospital's Chief Nursing Officer (CNO) and the Director of Nursing (DON) provided conflicting information regarding the investigation. The CNO indicated that the DON was conducting an investigation while the DON denied conducting an investigation.

Further review of the Investigation Summary indicated there was no documentation to support the Hospital completed a thorough investigation to include the outcome (substantiated or unsubstantiated) of the alleged patient abuse or implemented and/or monitored any system wide corrective actions in response to the delayed reporting of the alleged patient abuse and appropriately reporting and documenting new patient skin injuries.

During an interview on 8/15/23 at 10:30 A.M. and throughout the Survey, the Vice President of Quality, Risk, and Patient Experience acknowledged that her office did not investigate this incident but referred to the Hospital's Cooperate Employee Relations and Employee Relations Department investigation and Event Report, dated 3/6/23 . The Vice President of Quality, Risk, and Patient Experience Vice President of Quality, Risk, and Patient Experience said the Hospital did not develop and/or implement any system wide corrective actions in response to the delayed reporting of the alleged patient abuse and appropriately reporting and documenting new patient skin injuries.