HospitalInspections.org

Based on interview, record review, review of the facility's abuse policy, and review of the facility's incident report, it was determined the facility failed to ensure an allegation of abuse was reported immediately and that one (1) of ten (10) sampled patients (Patient #1) was protected from further potential abuse. Interview with a Patient Care Assistant (PCA) revealed on 01/24/18 at approximately 12:00 AM, PCA #1 observed that Patient #1 had a black eye. PCA #1 questioned the patient regarding the black eye, and Patient #1 made a fist and pointed to the PCA's badge, indicating that he/she had been struck by an employee. However, PCA #1 did not report the allegation until approximately 7:25 AM, seven (7) hours and twenty-five (25) minutes later and there was no evidence the patient was protected from further potential abuse.

The findings include:

Review of the facility policy titled "Abuse, Neglect, Exploitation of Patients and Reporting," adopted May 2017, revealed the facility would ensure patients would be free from all forms of abuse. Additional review revealed any staff member having reasonable cause to suspect that a patient had suffered abuse or neglect would immediately report the incident to their supervisor or the house supervisor.

Record review revealed the facility admitted Patient #1 on 12/29/17 with diagnoses including Acute Respiratory Failure, Chronic Pulmonary Obstructive Disorder, Aspirational Pneumonia, and Sepsis.

Review of a facility Incident Abstract Report, dated 01/24/18, revealed PCA #1 observed that Patient #1 had a black eye. Further review revealed PCA #1 questioned the patient regarding the black eye and Patient #1 made a fist and pointed to the PCA's badge, indicating that he/she had been struck by an employee.

Interview with PCA #1 on 01/29/18 at 6:05 PM revealed she was working with Patient #1 on 01/24/18 at approximately 12:00 AM, and observed that Patient #1 had a black eye. PCA #1 stated Patient #1 was nonverbal and when she questioned the patient regarding the black eye, the patient made a fist and pointed to her badge, and indicated to her that he/she had been struck by an employee. However, PCA #1 stated she did not immediately notify her supervisor or the house supervisor per the facility's policy and procedure and she did not report the allegation of physical abuse until the end of her shift on 01/24/18 at approximately 7:25 AM. Continued interview with PCA #1 revealed she had been trained on abuse and neglect reporting and knew she was supposed to report any allegation of abuse or neglect immediately to her supervisor or the house supervisor.

Interview with the PCA Coordinator on 01/29/18 at 3:34 PM revealed she was PCA #1's supervisor. Additional interview with the PCA Coordinator revealed PCA #1 reported the allegation of abuse/neglect regarding Patient #1 on 01/24/18 at approximately 7:25 AM. The PCA Coordinator stated she notified the Regulatory Affairs Officer of the allegation.

Interview with the Regulatory Affairs Officer on 01/29/18 at 2:41 PM and on 01/30/18 at 12:00 PM, revealed on 01/24/18 the PCA Coordinator reported the allegation of abuse/neglect, and an investigation was initiated. According the officer, the investigation was still in progress.