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Based on review of facility policy, review of staff education literature, medical record review, review of facility investigation documentation, and interview, the facility failed to implement the abuse policy for three patients (#1, #2, and #3) of seven sampled patients.

The findings included:

Review of facility policy Number: 8316.1055 titled, "Abuse Reporting" most recently revised in June 2005, revealed, "...When...staff has reason to suspect that the person has been the subject of abuse/neglect or exploitation, the appropriate authorities will be notified...If a hospital admitted patient demonstrates any of the criteria for abuse, Resource Management or House Supervisor/Administrative Representative...should be contacted for appropriate referral/notification...Staff Education...Issues of abuse will be presented at orientation...All employees will receive education...to identify and procedures for handling the victims of abuse and/or neglect."

Review of facility policy Number:8316.074 titled, "Occurrence Reporting; Serious Safety; and Sentinel Events" most recently revised in November 2010, revealed, "...outlines the procedure for identifying, reporting, responding to, and analysis of patient or visitor-related events, including Serious Safety and Sentinel Events, and the completion of an occurrence or incident report...The following is a non-inclusive list of sentinel events: Abuse...Occurrences will be reported by the (Hospital) employee or physician most closely involved in the situation (or who witnessed the incident) as soon as possible following the event...As part of the Hospital's non-punitive environment...staff may maintain anonymitty unless the event is the result of...events involving suspected patient abuse of any kind...Documentation in the medical record should include...brief, objective statement of the facts relating to the occurrence..."

Review of staff abuse education literature provided by the facility on June 12, 2013, revealed,"...This course will help you fulfill your legal and ethical duty to protect and serve patients. You will learn about: Patient abuse...after completing this course, you should be able to...Define types of abuse..Identify warning signs of abused patients and abusive providers...Protecting Patients: Best Practices...Report suspected abuse immediately..."

Review of a facility Investigation Report (Patient #1) dated February 25, 2013, revealed, "...Each incident involves the same nurse...Date of Occurrence: 12-20-12...information was made known on 2/14/13...nurse was witnessed penetrating the patient's rectum at least 7 times before determining that the patient did not have an impaction."

Review of a facility Investigation Report (Patient #2) dated February 25, 2013, revealed, "...Date of Occurrence: 12/26/12...The nurse yelled at the patient...and pulled the curtain to the room closed. A staff member heard this and turned on the monitor for that bed and watched the nurse grab the patient by the jaw and shove the NG (naso-gastric) tube back down...nostril in a very forceful and abusive manner."

Review of a facility Investigation Report (Patient #3) dated February 25, 2013, revealed, "...Date of Occurrence: 1/11/13...(Nurse B) was observed pushing on the patient's abdomen and inserting a finger into the patient's rectum to remove feces. Nurse B made comments about the patient's lack of sphincter tone and the color and consistency of the patient's feces..."


Patient #1 was admitted to the facility on December 19, 2012, with diagnoses including Dementia.

Medical record review of a Discharge Summary dated December 24, 2012, revealed, "...stable for discharge..." Medical record review revealed no documentation regarding abuse.

Patient #2 was admitted to the facility on December 23, 2012, with diagnoses including Pneumonia.

Medical record review of a Discharge Summary dated January 2, 2013, revealed, "...stable for discharge to Nursing Home..." Medical record review revealed no documentation regarding abuse.


Patient #3 was admitted to the facility on December 24, 2012, with diagnoses including Pulmonary Embolism. Medical record review of a nurse's note dated January 10, 2013, at 11:41 p.m., revealed, "...pronounced dead..." Medical record review revealed no documentation regarding abuse.

Interview with the Clincal Outcomes Coordinator on June 12, 2013, at 11:00 a.m., in an administrative conference room, revealed the facility was unaware of the allegations regarding Patients #1 and #2 until the allegations regarding Patient #3 were reported.

Interviews with the Risk Manager on June 12, 2013, at approximately 11:10 a.m. and 11:40 a.m., in an administrative conference room, revealed staff failed to report suspected abuse immediately and document in the medical record. Continued interview confirmed the facility failed to implement facility policy for Patients #1, #2, and #3.

C/O: #31264