HospitalInspections.org

Based on document review and staff interview it was determined the facility failed to ensure staff followed facility policy by reporting abuse of an incapacitated adult to Adult Protective Services (APS) for one (1) of ten (10) patients reviewed (Patient #1). This failure has the potential to place all incapacitated adult patients in the facility at risk of undetected, continued abuse by staff.

Findings include:

1. Facility policy entitled, "Abuse Neglect of Incapacitated Adults and Facility Residents," last revised 05/03/12, was reviewed on 04/20/15. It states, in part: "Any medical professional, who has reasonable cause to believe that an incapacitated adult has been abused, must immediately report the circumstances by telephone to the Adult Protective Services Agency (APS) in the county where the patient resides. The telephone report shall be followed by a written report within forty-eight (48) hours."

2. Patient #1's medical record was reviewed on 04/20/15. It revealed an admitting diagnosis, on 01/24/15, of altered mental status. Review of the History and Physical, dated 01/24/15, revealed the entry, "presents with confusion," and multiple entries stating: "Unable to obtain from the patient due to confusion." The record further revealed a consultation request for a neurologist for further evaluation. The only nursing note upon admission on 01/24/15 at 12:16 a.m. revealed the entry: "Video monitoring initiated on pt. d/t AMS (altered mental status)." The record further revealed consents for treatment were obtained from the patient's Medical Power of Attorney.

3. An interview was conducted with Video Monitoring Technician (VMT) #2 on 04/21/15, at 2:05 p.m. She stated she was working the night shift in the video monitoring room on 01/24/15. She was not assigned to view Patient #1 continuously that night, but did observe her frequently as the video monitoring room is small, with the monitor screens visible to both technicians. She observed an incident, which she considered verbal and physical abuse by staff, toward Patient #1 at 3:45 a.m. She reported the incident to a House Supervisor and was advised to complete an incident report at her earliest opportunity. She presented to the Day Shift House Supervisor at the end of her shift, gave a verbal report, and completed an incident report.

4. An interview was conducted with the House Supervisor on 04/21/15 at 10:10 a.m. She stated she arrived for day shift on the morning of 01/24/15, and recalled meeting with VMT #2 that morning. She stated VMT #2 made a verbal report of an alleged abuse incident during the night of a patient in unit 7NE. She advised the VMT to complete an incident report, then notified the Nurse Manager of unit 7NE, and the facility Director of Risk Management, of the incident. She was advised, by the Director, there was no need for her to do anything further. When asked, she denied filing an APS report on behalf of the patient.

5. A joint interview was conducted with the Nurse Manager and the Director of unit 7NE on 04/20/15 at 10:40 a.m. They agreed an internal investigation, conducted by the Nurse Manager, had been initiated as a result of an allegation of abuse of Patient #1, and reported all actions they had taken. When asked, they both agreed the patient fit the facility's definition of an incapacitated adult, and denied filing an APS report on behalf of the patient.

6. An interview was conducted with the Director of Risk Management on 04/21/15 at 10:35 a.m. She stated she clearly recalled the incident of alleged abuse of Patient #1, and agreed the patient fit the facility's definition of an incapacitated adult. When asked, she denied filing an APS report on behalf of the patient, and confirmed that, to her knowledge, no such report had been filed to date.