HospitalInspections.org

Based on staff interview and review of facility policy and procedure, it was determined the facility failed to ensure all complaints are documented and recorded in a complaint log.

Findings include:

On 7/12/23 at 10:29 AM, upon interview with Staff (S)3, a Patient Liaison from the Patient Experience Department, the following was revealed:

On 6/17/23, S3 had spoken to Patient (P)1 and his/her sibling about P2 (P1's roommate) allegedly throwing an object and hitting P1 in the right eye. S3 asked P1 if he/she wanted to report this incident to the police. P1 declined to report the event. S3 indicated the patient's family brought it to the nurse's attention. When S3 provided information on the seriousness of the event to P1, and asked again if P1 wanted to make a report of the event, S3 stated that P1 did not want to file a police report because P1 felt bad for P2. According to S3, P1 stated that he/she thought P2 was "crazy," and because of that, he/she did not want to involve the police. S3 stated that P1 was compassionate for P2.

The facility policy titled, "Complaint and Grievance Management," (dated 3/21) stated, " ... The patient Experience Department shall be responsible for addressing, coordinating, and documenting the response process to complaints/grievances brought to the Hospital's attention. ... All verbal or written complaints regarding abuse, ...are considered a grievance. ... All complaints/grievances received by the Patient Experience department shall be documented in the Patient Complaint/Grievance Log. ..."

On 7/12/23 at 10:25 AM, the documentation of P1's complaint and S3's interaction with P1 was requested from S3. The documentation was not received. Upon interview, S3 confirmed that he/she did not document this event, and no reason was given. This was not in accordance with facility policy.

Based on medical record review, staff interview, and review of facility documents, it was determined that the facility failed to ensure to report an alleged patient abuse incident in accordance with facility policy.

Findings include:

On 7/12/23 at 11:04 AM, Patient (P)1's medical record was reviewed in the presence of Staff (S)1, Director or Performance Improvement, S2, the Vice President (VP) of Patient Care Services and Chief Nursing Officer (CNO) and S5, a Clinical Informatics Specialist, and the following was revealed:

On 6/17/23 at 15:57 (3:57 PM), a "Nurse Simple" note, documented by a Registered Nurse (RN) indicated that P1's siblings were visiting that afternoon, and the sibling told the RN that "my [brother's/sister's] [P1's] right eye is swelling and can't see anything. [He/She] said the neighbor[P2] threw something onto [P1's] eye yesterday at 7:30 [PM]." The RN assessed P1 and called the house doctor.

On 7/12/23 at 12:30 PM, the Incident Report and any Grievances for P1 were requested. The incident report was received, reviewed, and found to be complete. The Incident Report dated 6/17/23, indicated that P1 declined filing a police report. S1 confirmed there were no grievances filed for P1.

On 7/12/23 at 12:47 PM, upon interview with S1, he/she indicated that the police were not involved because P1 declined to notify them. The facility policy for event reporting (including alleged abuse) was requested.

The facility policy titled, "Sentinel Event," (dated 7/20) was reviewed and stated, "... C. Categories of other NJDHSS (New Jersey Department of Health & Senior Services) reporting requirements ... include: Reporting to the Police all criminal acts or potentially criminal acts that occur within a facility and pose a danger to the life or safety of patients ..." Upon interview, S1 confirmed that the facility did not report this occurrence to the police. This was not in accordance with the policy for event reporting.