HospitalInspections.org

Based on the review of one of one medical record Patient (P)1, review of facility documents, and staff interview, it was determined the facility failed to ensure all incidents of alleged abuse are investigated.

Findings include:

Facility policy titled, "Incident Reports" reviewed 12/2023, states, "Policy: Any unusual patient/visitor/ volunteer or student incident (i.e., injury ...) must be reported on the form entitled "Hospital Incident Report". ...Procedure: A. Patient/Visitor Incident 1. A hospital incident report should be completed immediately following an incident; the employee involved in or observing the incident should complete the appropriate section of the report. 2. If the incident involves an injury to an inpatient, nursing personnel should arrange for the house/resident physician to examine the patient and should notify the attending physician. The house/resident physician should document physical findings in the progress notes of the medical record. ... 6. The completed incident report should be forwarded to the Risk Management within 24 hours of the incident for investigation purposes. ...".

Facility policy titled, "Implementation of Patient Rights" reviewed 12/2023, states, " ...Internal Abuse/Neglect -To the best of its ability, the hospital will protect patients from real/perceived abuse/neglect/exploitation from anyone, including staff, students, volunteers, other patients, visitors, or other family members. -All allegations, observations or suspected cases of abuse, neglect, or exploitation that occur in the organization are investigated by the organization. ...".

On 5/21/24 at 10:45 AM, medical record review was conducted with Staff (S)5 (Director of Psychiatry, Emergency Department). P1's medical record revealed, on 4/5/24 at 11:01 AM, that P1 presented to the main ED with a complaint of a fall. P1 had a medical history of seizures, depression, down's syndrome, Chronic Obstructive Pulmonary Disease, and hyperthyroidism. The ED RN (Registered Nurse) Note on 4/5/24 at 11:01 AM, stated, "Chief Complaint Quote: Pt [patient] presents to the ED from [group home] via EMS [Emergency Medical Services] for evaluation of trip and fall. A hematoma is noted on the right side of forehead. ...". On 4/5/24 at 1:00 PM, the RN Primary Assessment, stated, " ...INTEGUMENTARY- Systems: ...Wound Type #1 hematoma Would Location #1 forehead Wound Laterality #1 right Wound Appearance #1 clean/dry ...". The CT Scan Results from 4/5/24 at 12:48 PM, stated, " ...Right front scalp soft tissue swelling and hematoma. ...". P1 was discharged on 4/5/24 at 2:55 PM. On 4/11/24 at 10:47 PM, P1 presented to the Psychiatric ED, with a chief complaint of suicidal. P1 was transferred to the main ED on 4/11/24 at 11:36 PM for medical clearance. The Nursing Note from 4/11/24 at 10:47 PM, stated, " ...Pt was noted with swelling on right side of [his/her] forehead, bruising in various stages of healing around right eye and bruises on right thigh. ... [group home employees name] reported the injuries on pt's face and right thigh are from pt falling at the group home the previous week. ..." P1 was admitted to 6 South (Medical Unit) on 4/12/24 at 6:50 PM. The History and Physical from 4/12/24 at 9:27 PM, stated, " ...History of Present Illness ...patient had a fall a few days ago and now has a hematoma on her right scalp ....". On 4/18/24 at 4:55 PM, P1 was transferred and admitted to the psychiatric campus to an involuntary unit. The Psychiatric Evaluation from 4/19/24 at 3:56 PM, stated, " ...History Present Illness Patient is a [age] [male/female] with a past psychiatric history of autism spectrum disorder, intellectual developmental delay and schizoaffective disorder bipolar type ...It was noted that the patient had a hematoma on the right-side face from a fall a few days ago. ...The patient states that [he/she] fell before coming to the hospital. [He/she refuses to answer any questions about the fall. [He/she makes [his/her] needs known by stating [he/she] wants water or needs to go to the bathroom. The Nursing Note from 5/1/24 at 12:30 PM, stated, " ... Patient dishcharge [sic] to group home staff at 12:30 pm. During discharge, group home staff reported new bruises on [his/her] left orbital area that was not there when [he/she] came in. this writer also noted old bruises on [his/her] left orbital on upper eye lid. Staff ask patient how it happened and Patient reported "Amber" hit [him/her] when asked for help. No incident documented and there is no staff working here in D unit name Amber. Incident was notified to S6 (Nurse Manager), S9 (attending doctor), and S10 (Advanced Practice Nurse). ...".

At 11:16 AM, S3 (Quality and Patient Safety Manager), confirmed in front of S2 (Vice President of Behavioral Health), that there were no records on file of an incident report for P1.

At 1:25 PM, upon interview S6 confirmed he/she was notified by S8 (RN) of the allegation of abuse made by P1. S6 stated, "I saw [P1] upon arrival to the unit and the days leading to [P1's] discharge." S6 indicated P1 had bruising on his/her forehead and periorbital area from the fall before admission and that it was spreading from her forehead as "expected stages of healing." S6 stated there was no staff member named "Amber" on the unit, and P1 had not sustained any injury or fall during admission. S6 indicated since the group home staff had not visited P1 during his/her admission, the bruising may not look like what they expected it to look like. S6 indicated once he/she was made aware of the abuse allegation and alleged new bruising, he/she called and informed P1's group home that the bruising around the eye was from P1's previous fall and it was healing. S6 indicated the group home had no further questions. S6 stated, this conversation was not documented. When questioned, S6 confirmed he/she had not seen P1 for a couple of days prior to discharge. S6 confirmed a incident report was not completed.

At 1:57 PM, S6 confirmed P1's medical record lacked evidence of a physical examination, conducted by a physician, after P1 reported the alleged assault to S8.