HospitalInspections.org

Based on interview and document review, the facility failed to ensure nursing staff followed the facility's vulnerable adult (VA) policy and procedure when observed abuse was not reported in a timely manner for 1 of 1 patients (P1).

Findings include:

A Facility Reported Incident (FRI) report submitted to the State Agency (SA) on 6/15/23, identified P1 was verbally abusive to his wife during a phone conversation on 6/10/23 around 1:00 p.m. In response, registered nurse (RN)-B, who monitored the telephone conversation per the wife's request, "forcefully" removed the phone from P1's hand and stated, "Nope, we're not going to do that, you are done talking like that." After, P1 attempted to stand on his own in which RN-B "yelled" across the room, "[P1] sit down." P1 failed to sit down immediately and questioned why he was unable to talk with his wife. RN-B walked "briskly" over to P1, stood in front of him, and began "yelling" at him, "No, you're not going to talk to your wife because you yelled at her, you are supposed to love and protect her, not yell at her." P1 attempted to speak while RN-B yelled; however, he was unable to converse clear sentences. RN-B yelled, "It's not her fault that you're here, you are here because [doctor] wants you here and she can't take you out." Moments later, after RN-B returned to the computer charting area, P1 again raised his hand and stated, "But why can't she come and get me?" RN-B immediately walked to P1, stood in front of him, and yelled, "I already told you, she can't come and get you unless [doctor] says you can go and you're not talking to her until you can be nice." P1 sat "tapping on the arms of the chair and appeared to be threatened by [RN-B]." A staff member called out to RN-B three times to get her attention and to cease yelling at P1 before RN-B walked away from P1. RN-B stated to staff, "That stuff just gets to me" and if P1 was going to talk to his wife that way RN-B was "going to make sure he doesn't get to talk to her anymore." The report identified P1 continued to demonstrate "challenging behaviors" throughout the day which resulted in the need for intermuscular (IM) medications to remain calm. The report indicated disciplinary action and re-education was taken; however, the report lacked identification who was disciplined and re-educated or what re-education was provided.

P1's medical record identified P1 presented to the emergency department on 6/3/23 in response to worsening Alzheimer's dementia associated behaviors. He remained in observation status until he was admitted on 6/5/23 to the senior campus behavioral health unit, where he continued to be a patient. P1 demonstrated severe cognitive impairments, delusions, and aggression, and was a high fall risk patient. Per 6/10/23's progress notes, P1 started his day without any behavioral concerns; however, around 10:45 a.m. he attempted increased self-transfers and he voiced increased statements of wishing to go home. His behaviors were easily managed with scheduled medications and non-pharmacological interventions. Around 3:00 p.m. P1 was restless, continually self-transferred and was hyperfixated on going home. He was not easily directed and required PRN medication. P1's 6/10/23 progress notes lacked any details related to that day's phone conversation behaviors or associated staff interventions. P1's treatment and violence care plans directed staff to maintain a calm, non-threatening approach with P1 and to provide him with clear and consistent boundaries, while using a soft voice and de-stimulation techniques.

On 6/28/23 at 9:34 a.m., RN-B stated verbal abuse included yelling and/or screaming at a patient. She explained staff were expected to report abuse immediately, up to two hours but not later than 24 hours, to the charge nurse or unit manager to ensure patient safety. She stated the risks associated with failed reporting led to potential repeated occurrence(s), emotional injury, and/or physical injury. RN-B explained the events that surrounded P1's phone call to his wife and her responses. RN-B stated, due to P1's behaviors at that time, she used firm, clear, and direct words in an elevated tone of voice as P1 had hearing impairments and did not respond well to polite women. In addition, RN-B explained her intent was not to yell; however, P1 could not hear her, and as he yelled at her, she needed to get his attention. "In that moment I used the tone of voice needed for the situation, and the risk at hand, to keep everyone safe." RN-B denied she removed the phone from P1 forcefully, but acknowledged she retrieved the phone from him once she placed her hand over the phone in P1's hand and he released it. RN-B stated she worked on 6/11/23; however, had not worked since due to her every other weekend work status and the need for her to "shadow" a staff member before she was allowed to work on her own. She explained she was initially informed of the verbal abuse allegation on 6/16/23, a day after management was updated, and had since completed online learning modules related to abuse and communication.

On 6/28/23 at 10:53 a.m., NA-B stated she was expected to report abuse "right away" to the nurse manager to decrease risk(s) of the abuse from happening again. She explained RN-B "jerked" the phone from P1's hand on 6/10/23 after P1 yelled at his wife on the phone, and told P1 that was not how he was supposed to talk to people. NA-B stated P1 appeared "super confused" at that time. In addition, she explained RN-B stood over P1 in a "threatening pose" on two separate occasions after the phone call, and yelled at him about how he talked to his wife, in which P1 appeared "intimidated and scared." "[RN-B] was not [talking to] him in a calm voice." NA-B stated she did not report her concerns on 6/10/23 as expected because she feared retaliation; however, after she spoke to another staff member, she reported her concerns to the program director (PD)-A on either 6/12/23 or 6/13/23. NA-B denied she was provided education on abuse and/or reporting after the allegation.

On 6/28/23 at 11:24 a.m., PD-A stated yelling at a patient was verbal abuse and she expected staff to report abuse to her "as soon as they see it, know it, or hear it." If she was not in the facility, she expected staff to call her as it was extremely important to report abuse to ensure patient and staff safety. She explained if staff failed to report abuse there were increased risks for mental anguish and physical concerns to the patient. PD-A stated she started her role in March and was recently made aware the facility had concerns with timely abuse reporting in which the last VA report was "eye opening" for her. She stated she was under the impression staff were "scared to report" as they felt they would get into trouble or impact co-worker relationships if they reported abuse. She explained management was in the process of revamping their education process and were "educating as much as we can in the moment;" however, she denied NA-B or other facility wide staff were provided formal abuse and reporting education after she was updated on 6/15/23 about the incident with P1 and the identification of reporting timeframe concerns.

The facility Vulnerable Adult (VA) Policy dated 1/11/23, identified all patients had the right to be free from abuse in which the policy was used to ensure all identified cases of abuse were reported according to applicable licensing rules. The policy directed when facility personnel became aware of suspected VA abuse, they were to report their suspicions "immediately" to the administrator.