HospitalInspections.org

Based on interview and review of facility policy, it was determined the facility failed to provide care in a safe setting to one (1) of ten (10) sampled patients (Patient #2).

Patient Aide (PA) #3 and PA #5 alleged PA #4 punched Patient #2 in the stomach while they were assisting the patient with a shower; however, the PA's failed to immediately report the incident to their Supervisor and failed to remove PA #4 from resident care per facility policy.

The findings include:

Review of facility policy titled, "Reporting Patient Abuse", dated June 2018, revealed "For the protection of all patients, staff shall intervene immediately upon witnessing abuse". The policy defines intervene as ensuring patient safety and reporting an incident to his/her immediate supervisor.

Record review revealed the facility admitted Patient #2 on 06/22/17 with diagnoses which included personal history of Traumatic Brain Injury (TBI), and Major Neurological Disorder due to TBI.

Review of the facility investigation of an allegation that PA #4 punched Patient #2 in the stomach on 01/26/19 while assisting the patient with shower, dated 02/11/19, revealed the facility substantiated the allegation and terminated PA #4.

Interview with PA #4 on 02/18/19 at approximately 2:45 PM, revealed she did not punch Patient #2 in the stomach.

Interview with PA #5 on 02/19/19 at approximately 1:08 PM, revealed while she, PA #3, and PA #4 were assisting Patient #2 with a shower, she saw PA #4 punch Patient #2 in the stomach. She stated she did not immediately ask PA #4 to leave the area nor did she immediately report the incident to her supervisor. She revealed she waited to report the incident because PA #4 was in the nurse's office, so she went to the Coordinator's office to make the report and left PA #4 in the milieu with Patient #2 and other patients. PA #5 also stated she was not aware she could tell an employee to go sit in the nursing office if she had witnessed an act of abuse against a patient.

Interview with PA #3 on 02/18/19 at approximately 1:59 PM, revealed she, PA #4, and PA #5 were assisting with Patient #2's shower when she observed PA #4 punch the patient in the stomach. She stated she did not report the incident to anyone.

Interview with Registered Nurse (RN) #3 on 02/19/19 at approximately 8:27 AM, revealed she was the RN on duty on 01/26/18 when the incident occurred. She stated PA #5 and PA #3 should have told PA #4 to go to the nurse's desk immediately, made sure the patient was safe, and reported the incident to her immediately.

Interview with RN #4 on 02/19/19 at approximately 10:01 AM, revealed she was the RN Coordinator and PA #5 went to the coordinator's office to make a report of the incident. She stated she called the unit and had RN #3 pull PA #4 from direct care. She stated she told PA #5 she should have told PA #4 to leave the area and go to the nurse's office; and reported the incident immediately to the RN on the unit.

Interview with the Director of Nursing (DON) on 02/19/19 at approximately 8:53 AM, revealed she expected PA #3 and PA #5 to have removed PA #4 from the area right after they witnessed PA #4 punch Patient #2 and immediately reported the incident of abuse to the supervisor on the unit. She stated the incident was not handled according to policy.