HospitalInspections.org

Based on document review and interview, in three (3) of five (5) reports of abuse, the facility failed to protect and promote each patient's rights.

Findings:

The facility failed to:

(1) Ensure that complaints of abuse were investigated as grievances.
(See Tag A-0118)

(2) Establish procedures to direct and guide staff during abuse complaints.
(See Tag A-145)

Based on document review and interview, in 3 (three) of 5 (five) reports of abuse, the facility failed to investigate complaints of abuse as grievances.

Findings:

Review of a Complaint, dated 08/25/2024, identified that on 08/23/2024, Patient #1's family reported that while in the Emergency Department (ED), a Patient Care Associate (PCA) slapped Patient #1's leg and told them they smelled. The complaint was forwarded to the department manager for investigation on 08/26/2024, and on 08/30/2024, the investigation was completed.

Review of an Incident Report, dated 05/06/2024, identified Patient #4 self-reported that security officers "beat them up" while they were being medicated. The report noted that Patient #4 sustained a two-centimeter scratch on the right side of their face and a scratch on their left index finger.

Review of a Complaint, dated 10/12/2023, identified that Patient #5 self-reported that a PCA hit and shouted at them while having their vital signs taken on 10/12/2023. The investigation began on 10/13/2023, and on 10/17/2023, the investigation was completed.

There was no documented evidence that the complaint of abuse for Patient #1, the incident report for Patient #4, or the complaint of abuse for Patient #5 were investigated as grievances.

The facility's policy and procedure (P&P) titled, "Grievance Process/ Complaints/Complaint Management," last reviewed 04/26/2024, directed staff to investigate complaints of abuse as grievances.

During interview of Staff D (Director of Person-Centered Services Department) on 10/23/2024 at 11:09AM, Staff D shared that their department receives all complaints, and they forward the complaints to the department in which the event occurred for them to investigate. Staff D explained that their department staff are not clinical, and did not realize that complaints of abuse were to be investigated grievances. Additionally, Staff D stated that complainants do not receive notification about the results of the investigation unless they specifically request it.

During interview of Staff I (Network Director of Risk Management and Patient Safety) and Staff J (Chief Quality Officer) on 10/25/2024 at 10:46AM, both Staff I and Staff J confirmed that the complaints for Patient #1 and Patient #5, and the incident report for Patient #4, should have been investigated as grievances. Additionally, both Staff I and Staff J confirmed there were no documented staff statements, no collateral documentation gathered during these investigations, and that none of the complainants were informed about the results/outcome of the investigations.

These findings were brought to the attention of the facility's administrative personnel, Staff A (Network Director of Quality), Staff B (Director of Performance Improvement), and Staff C (Assistant Vice President of Hospital Operations), during the Exit Conference on 10/28/2024 at approximately 1:00PM.

Based on document review and interview, in three (3) of five (5) reports of abuse, the facility failed to establish procedures to direct and guide staff during abuse complaints.

Findings:

The facility's policy and procedure (P&P) titled, "Grievance Process/Complaints/ Complaint Management," last reviewed 04/26/2024, directed staff to investigate complaints of abuse as a grievance. The P&P lacked guidance directing staff in the process to follow during allegations and investigations of abuse.

Review of a Complaint, dated 08/25/2024, identified that on 08/23/2024, Patient #1's family reported that while in the Emergency Department (ED), a Patient Care Associate (PCA) slapped Patient #1's leg and told them that they smelled. The complaint was forwarded to the department manager for investigation on 08/26/2024, and on 08/30/2024, the investigation was completed.

During interview of Staff E (Clinical Nurse Manager) on 10/23/2024 at 1:09PM, Staff E shared that they initiated Patient #1's investigation on 08/29/2024 by speaking with the patient, their family, and with Staff L (PCA) who was on duty at that time. Staff E confirmed that they do not remove staff members from patient care during abuse investigations, and they did not gather any written statements from potential witnesses. Additionally, Staff E explained that they do not make the decision to review security camera footage or involve the security department during an investigation, but that staff from the Person-Centered Services Department does.

During interview of Staff D (Director of Person-Centered Services Department) on 10/23/2024 at 2:01PM, Staff D explained that their department does not involve the security department in an investigation that does not directly involve them, but that the manager from the department investigating the complaint can request to review security camera footage.

Review of an Incident Report, dated 05/06/2024, identified Patient #4 self-reported that security officers "beat them up" while they were being medicated. The report noted that Patient #4 sustained a two-centimeter scratch on the right side of their face and a scratch on their left index finger.

The Psychiatric Performance Improvement Follow-Up Investigation Call for Assistance/Dr. Strong Form, dated 05/06/2024, identified the following staff were present when Patient #4 was medicated and placed in restraints: Staff N (Sergeant), Staff O (Security Officer), Staff P (Security Officer), Staff R (Registered Nurse) and Staff S (Registered Nurse).

During interview of Staff T (Assistant Director of Nursing) on 10/23/2024 at 1:05PM, Staff T confirmed that the security officers and nurses were not interviewed because the complaint was against the security officers, and security conducts the investigation.

During interview of Staff U (Director of Security) on 10/23/2024 at 3:00PM, Staf U stated, "I never received a report about the complaint and was not aware of the complaint. I did not do an investigation."

Review of a Complaint, dated 10/12/2023, identified that Patient #5 self-reported that a PCA hit and shouted at them while having their vital signs taken on 10/12/2023. The investigation began on 10/13/2023, and on 10/17/2023, the investigation was completed.

During interview of Staff A (Network Director of Quality) on 10/24/2024 at 2:45PM, Staff A confirmed that the PCA associated with Patient #5's abuse allegation was not removed from patient care, and no written statements were collected.

There was no documented evidence that the complaint of abuse for Patient #1, the incident report for Patient #4, or the complaint of abuse for Patient #5 were thoroughly investigated, and there were no established or implemented facility-wide guidelines/procedures to direct or guide staff in the process to follow during allegations and investigations of abuse. Additionally, upon request, the facility was unable to provide the following information regarding the above investigations: (1) Documented statements about the incidents; (2) Documented evidence that the 'alleged' abuser was removed from patient care responsibilities; (3) Documented evidence that the investigator, nursing staff, and/or physician performed an assessment to determine if there were injuries or the extent of injuries; and (4) Documented evidence of the investigation outcomes.

During interview of Staff I (Network Director of Risk Management and Patient Safety) and Staff J (Chief Quality Officer) on 10/25/2024 at 10:46AM, both Staff I and Staff J confirmed that there were no documented statements, collateral documentation gathered during these investigations, and no established or implemented facility-wide guideline/procedure currently in place to direct and guide staff during abuse investigations.

These findings were brought to the attention of Staff A (Network Director of Quality), Staff B (Director of Performance Improvement), and Staff C (AVP spell out of Hospital Operations), during the Exit Conference on 10/28/2024 at approximately 1:00PM.