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Based on interviews, medical record review, and document review, it was determined the facility failed to substantially comply with this condition by:

failed to report an allegation of abuse within twenty-four (24) hours to the Department of Social Services (DSS) and failed to immediately report a serious safety event (SSE) to Patient Safety/Risk Management (MR2 - Patient over 60 years of age). (A145); and

failed to obtain a physician's order for the use of restraints (A168).

Based on interviews, medical record review, and document review, it was determined the facility failed to substantially comply with this condition by:

failed to ensure adverse events are entered consistently and timely for tracking and analysis (A-0263) and;

failed to demonstrate QAPI activities to improve patient safety specifically related to falls and allegations of abuse (A-0309).

Based on medical record (MR) review, document review and interviews, it was determined the facility failed to report an allegation of abuse within twenty-four (24) hours to the Department of Social Services (DSS) and failed to immediately report a serious safety event (SSE) to Patient Safety/Risk Management (MR2 - Patient over 60 years of age).

Findings:

The facility's policy titled, Facility Event and Close Call Reporting Policy and Procedure (last revised May 2024), partly reads: "... POLICY: ... Event reports should be completed as soon as possible after the event, but no later than the end of the shift... PROCEDURE: ... II. Initial Event and Close Call Report Review A. Serious events, as defined in the Serious Safety Event Identification, Notification, and Management Policy..., should immediately be reported to the Patient Safety/Risk Management department...".

The facility's policy titled, Serious Safety Event Identification, Notification and Management (last revised February 2024), partly reads: "... PROCEDURE: ... Identification ... 2. ... the list below contains some events that meet the SSE criteria; however, this is not an exhaustive list: ... g. Sexual abuse/assault* of any patient receiving care, treatment, and services while on site at organization or while under the care or supervision of the organization... *Defined in Key Terms section of this policy. Notification Internal 1. When an SSE has occurred: a. Supervisor will immediately notify patient safety/risk management b. Patient Safety / Risk Management: i. Will notify executive leaders and other key individuals as appropriate ii. Initiate internal response within sixty (60) minutes of discovery of the vent when possible to: 1. Ensure patient care and second victim needs are met 2. Begin preliminary fact-finding investigation 3. Identify the appropriate next actions 4. Coordinate all communications 5. Assign responsibility for the initial communication with the patient and/or the patient's representative/family and/or support person. External 1. Patient Safety / Risk Management will utilize the approved event reporting platform... to initiate SSE notification to provide initial relevant facts to key stakeholders... 3. All reporting requirements for mandatory or voluntary notifications of state and federal law enforcement, and regulatory / accrediting agencies should be completed per the agency's reporting requirements... and specified timeframes...".

The facility's policy titled, Abuse and Neglect Identification and Reporting (effective December 2023), partly reads: "POLICY STATEMENT: It is the policy of [Name of facility], in case of suspected or confirmed abuse, neglect, exploitation or domestic violence to, upon initial assessment: ... 3. Carry out the legal obligations of reporting abuse, neglect and/or exploitation according to state law... PURPOSE STATEMENT To establish guidelines for reporting obligations, identification, and protection of vulnerable patients who may be in danger of abuse, neglect or exploitation including: 1) children, 2) victims of domestic violence, 3) incapacitated persons 18 years and over, and 4) persons over 60 years of age... DEFINITIONS ... Sexual assault - Any illegal sexual act including incest, rape, indecent exposure... PROCEDURE: 1. Reporting Abuse or Neglect. Mandated reporters directly involved in the care of the patient must report all suspected abuse, neglect, and exploitation of children, incapacitated adults and elders within 24 hours to the local welfare/social services agency of the county or city where the individual resides, or where the abuse is believed to have occurred... 6. As soon as possible, the individual who has assessed abuse should inform department leadership, who will inform executive leadership of suspected cases of abuse. This purpose is to assure there is proper internal notification of potential risks to victims and patients... DOCUMENTATION Documentation in the medical record is essential in order to protect the patient and for the outcome of any legal case. Records should include, whenever possible: 1. Chief complaint and description of abusive event, using the patient's own words... 9. The Protective Services report including the agency, telephone number, contact person, and the basis for the report...".

During an interview with EMP10 on January 27, 2025, EMP10 indicated that they and EMP17 were in the room with MR2 (on 01/13/2025) when the patient stated, "that man was in here earlier." MR2 continued that the man was touching himself and forcing MR2's head down. EMP10 indicated that MR2 was upset while telling the account. EMP10 further stated when asked about mandatory reporting of abuse to DSS "I know about mandated reporting in Pennsylvania, but didn't know if it applied in Virginia."

During an interview conducted with EMP3 on January 29, 2025, EMP3 indicated the facility "cannot contact APS [Adult Protective Services] for every confused patient we have who may be having a nightmare". EMP3 indicated that staff "are not prevented from reporting" and if "anything" is identified during the investigation that "supports an allegation" then "we would report."

The SSE identification and notification policy directs staff to notify patient safety/risk management immediately when a SSE occurs; however, during an interview with EMP11 (patient safety/risk management) on January 27 and January 30, 2025, EMP11 indicated they were notified of MR2's allegations of sexual abuse/assault on January 22, 2025 (nine days later).

Upon review of MR2, there was no evidence found to demonstrate mandatory reporting of the abuse allegation occurred to DSS within twenty-hour hours (24) or the SSE was reporting to patient safety/risk management immediately when the SSE occurred.

Based on medical record reviews, interview and document review, it was determined that the facility failed to receive orders prior to or immediately after initiation of a non-violent restraint in one (1) of four (4) medical records reviewed (MR6).

The findings include:

The facility's policy entitled, "Patient Restraint/Seclusion," policy number COG.COG.001, effective date September 2023, reads in part:
... "Procedure:
... 5. Order for Restraint or Seclusion
a. An order for restraint or seclusion must be obtained from a physician or other licensed practitioner who is acting within their State Scope of Practice, authorized by State law as having authority for ordering restraints, and is responsible for the care of the patient prior to the application of restraint or seclusion.
... d. When a physician or other licensed practitioner, authorized by State law to order restraints, is not available to issue a restraint or seclusion order, an RN with demonstrated competence may initiate restraint or seclusion use based upon fact-to-face assessment of the patient. In these emergency situations, the order must be obtained during the emergency application or immediately (within minutes) after the restraint or seclusion is initiated."

On January 27, 2025, at 10:30 A.M., the medical records for MR5 through MR8 were reviewed with the assistance of EMP6 acting as navigator.

At 9:05 A.M. on December 20, 2024, MR6 received bilateral upper extremity soft restraints. The non-violent restraints were initiated because MR2 was attempting to remove an intravenous line and other alternatives were unsuccessful. Documentation in the record reveals that the order for the restraints was obtained from the provider at 6:35 P.M., approximately nine and one-half (9.5) hours after initiation. All safety checks and monitoring were documented and within guidelines. During the record review, EMP6 agreed that an order for the usage of the restraints should have been obtained immediately from the physician after initiation by the nurse.

Based on document review and interviews, it was determined the facility failed to ensure adverse events are entered consistently and timely for tracking and analysis.

Findings:

The facility's policy titled, Facility Event and Close Call Reporting Policy and Procedure (last revised May 2024), partly reads: "... POLICY: ... Event reports should be completed as soon as possible after the event, but no later than the end of the shift...".

A document titled, Reporting Safety Events, was reviewed by the surveyor. Per EMP3, the presentation is reviewed with new employees during orientation. Bullet point three on page 5 of the presentation reads, "Report the event as soon as possible after the event, but before the end of your shift".

During an interview with EMP10 on January 27, 2025, EMP10 indicated that they and EMP17 were in the room with MR2 (on 01/13/2025) when the patient stated, "that man was in here earlier." MR2 continued that the man was touching himself and forcing MR2's head down. EMP10 indicated that MR2 was upset while telling the account.

A review of the facility's adverse event log for January 1, 2025 through January 27, 2025 (requested on 01/27/25) did not contain an entry for MR2.

An additional adverse event log for June 1, 2025 through January 28, 2025 was requested and received on January 29, 2025 at 9:06 AM. A review of the log indicated an event had been entered for MR2; January 12, 2025 as the "date of event" and January 27, 2025 as "date reported".

Based on document review and interview, it was determined the facility failed to provide evidence of actions aimed at performance improvement. Specifically, the facility failed to demonstrate QAPI activities to improve patient safety specifically related to falls and allegations of abuse.

Findings:

During an interview with EMP10 on January 27, 2025, EMP10 indicated that they and EMP17 were in the room with MR2 (on 01/13/2025) when the patient stated, "that man was in here earlier." MR2 continued that the man was touching himself and forcing MR2's head down. EMP10 indicated that MR2 was upset while telling the account.

On January 27, 2025, the state agency (SA) requested evidence of the facility's investigation into MR2's abuse allegation.

On January 29, 2025 at 8:50 AM, the SA received copies of the Quality and Safety Committee meeting agenda from February through December, but no minutes. The SA inquired about the minutes, EMP3 indicated specific information from the meetings is sent to the Patient Safety Organization (PSO) and is "unavailable".

A review of the adverse event log from June 1, 2024 through January 27, 2025 revealed there were eighty-one (81) events labeled "Fall". During a discussion about QAPI, the SA requested evidence of the facility's efforts to improve falls. EMP3 indicated information could be redacted and the minutes shared with the SA. The SA requested any evidence to support the facility's QAPI activities.

At 1:38 PM, the SA was provided a copy of the December 2024 Quality and Patient Safety Committee redacted minutes. The following sections were redacted or partially redacted: Approval of minutes; Safety Reports/Trends/Alerts/SS Action Plans; Grievances; Falls Prevention; Telemetry Safety; HAPI Prevention; Suicide Prevention; Infection Prevention; Restraints; Resuscitation; BERT/Workplace Safety; Dept Quality Excellence Reports (each unit listed under this title was redacted); Quality Construct Performance; and Open Discussion.

The SA requested the meeting minutes from June 2024 through November 2024. At 3:01 PM, EMP3 provided the minutes; the minutes were redacted the same as the December 2024 minutes.

The SA was unable to determine what areas of opportunity have been identified and what QAPI activities are active to improve patient safety specifically related to falls and allegations of abuse.