HospitalInspections.org

Based on document review and interview, it was determined that the Hospital failed to protect and promote patient's rights by failing to ensure appropriate steps were taken regarding a patient's allegations of abuse. This potentially places any patient in the Hospital at risk for serious harm, serious injury or serious impairment. As a result, the Condition of Participation 42 CFR 482.13, was not in compliance.

Findings include:

1. The Hospital failed to ensure patient was free from all forms of abuse by failing to follow the response and notification processes for allegations of abuse. See deficiency A-145.

The Immediate Jeopardy (IJ) began on 5/05/2022 due to the Hospital's failure to ensure a patient was free from all forms of abuse by failing to follow measures in accordance with policy and procedure regarding allegations of physical and sexual abuse. The IJ was identified on 1/19/2023 at 42 CFR 482.13, Patient Rights, and was announced on 1/19/2023 at 1:15 PM, during a meeting with the Director of Nursing, Director of Performance Improvement and Risk Management, and Assistant Director of Nursing. The IJ was not removed by the survey exit date of 1/19/2023.

Based on document review and interview, it was determined that for 2 of 5 patients' (Pt. #1 and Pt. #2) clinical records reviewed regarding care planning, the Hospital failed to ensure that the patient participated in the development and implementation of the care/treatment plan.

Findings include:

1. On 1/17/2023, the clinical record for Pt. #1 was reviewed. Pt. #1 was admitted on 4/24/2022 with a diagnosis of unspecified psychosis (mental condition affecting perception of reality) due to substance abuse. Treatment plans were developed and implemented for Pt. #1 on 5/11/2022, 5/18/2022, and 5/25/2022. The plans did not indicate that Pt. #1 was aware and participated in the development and implementation of the plans. The plans also did not indicate that Pt. #1 refused to sign the plans.

2. On 1/18/2023, the clinical record for Pt. #2 was reviewed. Pt. #2 was admitted on 12/9/2022, with diagnoses of major depressive disorder and psychosis. Treatment plans were developed and implemented for Pt. #2 on 12/21/2022 and 12/28/2022. The plans did not indicate that Pt. #2 was aware and participated in the development and implementation of the plans. The plans also did not indicate that Pt. #2 refused to sign the plans.

3. On 1/18/2023, the Hospital's policy titled, "Interdisciplinary Treatment Planning Process" (reviewed by the Hospital on 1/2022) was reviewed and required, "Policy... Patients, families and significant others are involved in the treatment planning process... Procedure... Social Worker... Ensures that the patient actively participates in the development of the treatment plan... Social Worker... shares the information with the patient and family and obtains the patient's signature for each individual treatment plan..."

4. On 1/18/2023 at approximately 12:52 PM, findings were discussed with E #10 (Social Worker). E #10 stated that she is responsible for making sure that patients and/or families are aware regarding the development and implementation of patient's treatment plan. E #10 agreed that treatment plans should be signed by the patient or patient's family.

Based on document review and interview, it was determined that for 1 of 1 patient's (Pt. #1) record reviewed regarding allegations of abuse, the Hospital failed to ensure patient was free from all forms of abuse by failing to follow the response and notification processes for allegations of abuse. This has the likelihood to cause serious harm to any patient admitted in the Hospital.

Findings include:

1. The Hospital's policy titled, "Suspected Abuse/Neglect of Patients" (reviewed by the Hospital on 3/2022) included, " ... If physical or sexual abuse ... is reported or suspected with any individual or family during an assessment ... screening and documentation of the abuse ... will occur ... Action Steps ... 3 ...If Patient needs immediate medical attention, Nurse in consultation with Medical Staff determine if transport to medical hospital for further evaluation and treatment is warranted ... Social Worker acts as facilitator and maintains contact with the investigation team until investigation is complete ..."

2. The Hospital's policy titled, "Sexual Allegation, Aggression and Sexual Victimization: Prevention Response and Notification Plan" (dated 3/2022) included, " ... To provide a response and notification plan in the event of a sexual allegation ... 5. Response to Sexual Allegation ... Initiate investigation including interviews of the patients involved, any witness(es), and staff directly responsible for the observation rounds at the time of the event ... Notify ... Nursing Supervisor of incident. Offer patient(s) transport to the ER for rape/trauma evaluation for cases ... Complete an ...Incident Report during the shift (for) the incident (that) occurred, and document incident in patient's medical record ... 6 ... Notify the Charge Nurse immediately. Charge Nurse will notify the Nursing Supervisor ... Nursing Supervisor: Notify Director of Risk Management ... Director of Risk Management ... will notify the police of the incident ... Attending MD. Reviews all relevant findings with the patient(s) involved and documents the discussion and patient response in the medical record ... Assess whether a trauma consult is needed and/or additional therapy for the patient ... Director of Risk Management/Designee ... Initiate/Oversee Investigation ... Review documentation in the medical record regarding the alleged incident, notifications, staff interventions, and patient response ..."

3. On 1/17/2023 at approximately 8:45 AM, any/all incident reports and investigation conducted regarding Pt. #1 were requested. At approximately 11:30 AM, E #8 (Director of Performance Improvement and Risk Management) confirmed that there were no incident or investigation reports for Pt. #1.

4. On 1/17/2023, the clinical record for Pt. #1 was reviewed. Pt. #1 was admitted to the Hospital on 4/24/2022 with a diagnosis of unspecified psychosis (mental condition affecting perception of reality) due to substance abuse. The clinical record included:

- On 4/25/2022, MD #1's (Attending Psychiatrist) psychiatric assessment indicated that Pt. #1 was alert, oriented to person, place, time, and situation. Pt. #1 denied/has no history of sexual, emotional, or physical trauma/abuse.

- On 5/5/2022, E #10's (Social Worker's) note indicated, " ... (Pt. #1 stated) ... they had me sleeping on the floor; they have raped me and bruised me, now they are keeping me here until all the bruises go away ..."

- On 5/5/2022, 5/6/2022, and 5/10/2022, MD #1's assessments indicated that Pt. #1 was oriented to time, place, person, and situation. On 5/5/2022, " ... (Pt. #1) thinks that when she was in the emergency room, she was abused ..." On 5/6/2022, " ... (Pt. #1) has been writing (a) note saying that she has been assaulted over here (at the Hospital) ..." On 5/10/2022, " ... (Pt. #1) said she wants (a) medical doctor to examine the abuse (that) she is sustaining over here (at the Hospital) by the nurses in the bathroom ..."

- Following Pt. #1's allegations of abuse, the clinical record did not indicate that the Charge Nurse, Nursing Supervisor, and the Director of Risk were notified.

-The clinical record did not indicate that a medical doctor examined Pt. #1. There was also no consultation with medical staff to determine if transport to medical hospital for further evaluation and treatment was needed.

5. On 1/18/2023 at approximately 10:45 AM, findings were discussed with MD #1 (Attending Psychiatrist). MD #1 stated that Pt. #1 made allegations of physical and sexual abuse. MD #1 stated that he reported the allegations of abuse to the Director of Risk Management. MD #1 stated that whether a patient has psychosis or delusions (false beliefs), an investigation should be conducted to ensure patient safety. MD #1 stated that failure to investigate may cause physical or emotional distress to the patient.

6. On 1/18/2023 at approximately 12:18 PM, an interview was conducted with E #8. E #8 stated, "When a clinician receives an allegation of abuse, the Charge Nurse and the Risk Management (E #9) will be notified. An incident report will be written, and an investigation will be initiated. The Medical Physician will also be notified to examine the patient. Steps taken will be documented in the patient's clinical record. E #8 stated that he did not receive notification regarding Pt #1's allegations of abuse.

7. On 1/18/2023 at approximately 12:52 PM, an interview was conducted with E #10 (Social Worker). E #10 stated that Pt. #1 made an allegation of abuse. E #10 stated that she was not involved in the investigation regarding the allegation of abuse made by Pt. #1.

8. On 1/18/2023 at approximately 1:08 PM, an interview was conducted with E #9 (Risk Management). E #9 stated that there was no incident report written nor investigation conducted regarding Pt. #1's allegation of abuse. E #9 stated, "I was never aware."