HospitalInspections.org

Based on medical record review, document review, policy review, and interview, the Hospital failed to ensure a prompt investigation of an allegation of abuse for 1 of 9 patients (Patient 6) reviewed and failed to show evidence patients were protected during the investigation. This deficient practice has the potential to cause patient harm or other adverse outcomes.

Findings Include:

Review of the Hospital's policy titled, "Complaint and Grievance Process" revised on 10/01/22, showed, "Hospital staff member receiving the complaint will initiate the complaint/grievance form and address the concerns that are appropriate to the individual's area of responsibility, expertise, state practice guidelines, experience, and knowledge and can be addressed immediately. The hospital staff member will complete the complaint/grievance form through Section C, sign, and date the form and forward it to the DQM (Director of Quality Management). The investigative procedure should be completed, corrective action taken, and a written response sent within 7 days of receipt of complaint.

Review of the Hospital's policy titled, "Abuse and Neglect" with an issue date 01/01/23 showed, " ...An allegation of abuse of a patient by staff, visitors or other patients will result in removal of the patient (and others, as indicated) from any potential for harm or injury. Additionally, the Corporate Legal Department will be notified and if the allegation involves an employee the Corporate Human Resources Director will be notified. There will be no delay in removing patients from potential of danger pending notification and investigation." ...

Section 5, titled, "Protection of Patients," included: "Any allegation of abuse or neglect by an employee must result in removal of the patient from potential of further abuse. Any employee involved in such an accusation will be suspended with pay and instructed not to come to the hospital, until the investigation is completed, and the matter resolved. The Chief Executive Officer (CEO) or designee will begin the investigation with the advice and counsel of the Corporate Legal and Human Resources Departments." ...

Section 6 titled investigation: " ...All investigations will be prompt and thorough." ...


Patient 6

Review of P6's "History and Physical" (H&P) showed Patient 6 admitted on 12/13/22 with; the following diagnoses: acute renal failure syndrome, acute respiratory failure with hypoxia, chronic pain, coronary atherosclerosis (carries blood to the heart muscles, may block the artery), diabetes, coronary artery disease, acute left cerebral artery cerebrovascular (stroke) accident and right sided hemiparesis (muscle weakness). Tracheotomy (opening surgically created through the neck into the windpipe to allow air to fill the lung) and Percutaneous endoscopic gastrostomy (PEG - feeding tube through the skin and the stomach wall) tubes were placed on 12/07/22.

Review of Patient 6's nursing note dated 12/15/22 at 11:30 AM by Staff H, Nurse Manager showed, "Staff P House Supervisor reported to this RN that the patient was reporting sexual assaulted by a black man last night. I personally went to the room to talk to the patient and Patient 6's daughter was at bedside. I asked the patient if something had happened last night. She said no. I asked her if she feels safe. She said yes. I asked her if anything has happened here to make her feel uncomfortable. She said no. I asked her if she wanted us to have only females care for her and she said it doesn't matter, who is it? In between questions patient spoke incomplete sentences that did not make sense and appeared very confused."

Review of a nursing note dated 12/15/22 at 12:30 PM, by Staff H showed, Patient's 6's daughter was requesting that she be transferred to another facility because she was unhappy about the whole situation. Staff H documented, "We had a conversation with her and let her know that we take all accusations seriously and if she wanted us to call the police and start an investigation that we would be more than happy to do so. She stated at this time she did not want to persue (sic) this route but will speak to her step dad when he arrives and let us know if they change their mind. We also determined it would be best to make her female care and care in pairs."

Review of "Incident Report" dated 12/23/22 showed the investigation of the allegation of abuse was initiated on 12/20/22 (five days after the reported incident). On 12/20/22 Staff Y, Interim Director of Quality Management (IDQM) spoke with Staff A Chief Nursing Officer (CNO), Staff H, Nurse Manager and Staff C, Chief Executive Officer (CEO) as well as contacting the facilities legal department. It was determined that the facility should follow our process and formally address as an abuse allegation." The allegation of abuse/incident occurred on the 12/14/22 evening shift and was reported on 12/15/22 at 11:30 AM. The incident report showed Staff K, RN was suspended on 12/20/22 at 12:00 PM.

Review of the "Daily Assignment Sheet" for the timeframe of 12/14/22 to 12/22/22, showed Staff K Registered nurse (RN) worked the night shift on 12/14/22, 12/15/22, 12/18/22, 12/21/22 and 12/22/22.

During an interview on 05/17/23 at 12:20 PM with Staff A Chief Nursing Officer (CNO), regarding why there was a delay in the investigation of the allegation of abuse reported by Patient 6 on 12/15/22, Staff A stated, "We were out of the office at the time. It would have flowed a lot differently. We need to follow our procedures. We had an opportunity to expedite the process more quickly. An opportunity for all leaders on call to know that process."

During a subsequent interview on 05/17/23 at 3:20 PM, Staff A CNO, when asked why the hospital waited 5 days to suspend the Staff K RN, Staff A stated, "I don't know." We had a call with the regional office, and it was decided to suspend the staff member"

During a telephone interview on 05/18/23 at 9:22 AM Staff K, RN stated, I don't think I was suspended. I was off for the few days."

During an interview on 05/18/23 at 2:40 PM, with Staff V, Human Resource (HR) Coordinator regarding suspension of Staff K revealed, she followed-up with regional. Staff K stated, "There is no formal documentation. It is done verbally, phone call or in person."