HospitalInspections.org

Based on document review, policy review, medical record review, and interview, the hospital failed to promote a hospital wide system that would ensure abuse prevention and protection for all patients.

The findings included:

The hospital failed to immediately report and respond to an allegation of abuse to ensure all the patients were protected, and measures were implemented to ensure patients were protected and free from further potential abuse.
Refer to A 145.

Based on document review, policy review, medical record review, and interview, the hospital failed to ensure all staff reported incidences of abuse in a timely manner in order to ensure measures were implement timely to protect all patients from abuse and harassment for 1 of 3 (Patient #1) sampled patients.

The findings included:

1. Review of the facility's "ALLEGATION OF PATIENT ABUSE/SUSPICION OF DOMESTIC ABUSE OR NEGLECT..." policy documented, "...It is the policy of [Hospital Initials] to immediately and effectively investigate and resolve any allegations of patient abuse. This policy applies to any [Named Hospital] personnel who discovers witnesses or receives information related to the suspicion of abuse/neglect of any patient. This policy also applies to any employee suspected of abuse/neglect of a patient...Types of Abuse...Physical - Any inflicted injury by the...caretaker of a...patient...Verbal - Use of oral, written or gestured language that willfully includes disparaging and derogatory terms to patients or within their hearing distance, regardless of age, ability to comprehend or disability...Emotional - Failing to provide a nurturing environment in which an individual can fully develop emotionally and intellectually...The Nurse and/or Supervisor will notify the Director of the department to initiate action to be taken and investigate investigation...The Nurse and/or Supervisor...Carefully assess the patient.. Immediately notify the physician...for further orders...Carefully document in the written record...should be objective and as much detail as possible should be included...The Physician Will assess/reassess patient for abuse/neglect after notification...The Nurse-in-charge...notify the Social Worker....Manager/Director...An investigation of the alleged perpetrator (employee...) will be conducted by the manager / director in consultation with the Risk manager / director in consultation with the Risk manager...For protection of the patient and employees, the employee should be suspended immediately pending investigation...The Risk Manager/Patient Safety Officer makes notification to the Tennessee Department of Health in accordance with the State guidelines for reporting..."

2. Medical record review revealed Patient #1 was admitted to the hospital on 5/24/18 with diagnoses of Acute Ischemic Stroke, Encephalopathy, Acute Alcohol Intoxication, and Sinus Bradycardia.

A physician progress note dated 9/15/18 documented, " ...Patient agitated and attempting to get out of bed ...Confused, mildly agitated.

A Consult Preliminary Note dated 9/18/18 documented, " ...REASON FOR CONSULT confusion in restraints ...BEHAVIORS :irriabliety [irritability] ...INSIGHT/JUDGEMENT:impaired ..."

The hospital's abuse investigation document revealed an incident had occurred on 8/29/18 on the 7:00 PM to 7:00 AM shift. The document stated that Witness #1 reported the alleged abuse on 9/3/18 to the supervisor (4 days later).

The supervisor sent an email on 9/3/18 to the Nurse Manager who was not working that day (Labor Day).

The hospital leadership team began the investigation on 9/4/18. The investigation revealed 3 witnesses saw and heard Registered Nurse (RN) #1 become verbally and physically aggressive with Patient #1.

Review of a typed email statement from Witness #1 dated Monday 9/3/18 and sent to the supervisor, revealed" ...I witnessed [Named RN #1] being both verbally and physically abusive to the patient [Named Patient #1]. During this encounter, [Named RN #1] yelled, cursed, and aggressively jerked at the patient ' s restraints and body ...[Named RN #1] elbowed [Named Patient #1] in the back very roughly until he had pushed him out of the way all the while saying, ' Sit up [Patient #1's Last Name] Sit up ' . At another moment ...leaned down in the patient's face and yelled, ' Your woman is gone! She's moved on! Ain't nobody coming for you ' ..."
A typed email statement from Witness #3 dated Tuesday 9/4/18, and sent to the supervisor, " ...I do recall him [RN #1] loudly yelling, using profanity, at the patient to stop what he was doing and get back in bed ...the patient had pulled out two tracheostomies that night ...his frustrations with the patient were not handled in a professional manner and could have been handled much more appropriately ..."

A handwritten statement from RN #1 was given to his supervisor on 9/7/18 and verified the written statement was accurate. The statement documented, " ...On August 28, 2018, I was taking care of Resident [Named Patient #1 Last Name]. This resident was very difficult on this shift. He had pulled off his condom cath [catheter] and while I was giving him a bath, he pulled out his trach. I remember saying what is your problem. This resident is fully alert and aware of his actions ...I came out of resident ' s room and told ...that I was sick of taking care of this patient. I did not physically abuse this pt. [patient] ..."

A typed email statement from Witness #2 dated Tuesday 9/11/18 and sent to the supervisor, " ...I saw [Named RN #1] being very aggressive towards the patient. He was pulling on his restraint (on the right side). He then leaned into [Named Patient #1] and said "Your woman is gone, she ' s moved on. Ain ' t no one coming for you ..." Witness #2 was not interviewed. 2 messages were left to return the call with no response.

Interview with the Patient Safety Officer on 10/1/18 at 1:30 PM in the administration office, she was asked about the allegation of abuse. She stated that she began the investigation on 9/4/18 and obtained statements from the witnesses. She confirmed that RN #1 was also terminated. She stated that when they are notified of the allegation they put the staff member on administrative leave.

Interview with the Chief of Human Resources on 10/1/18 at 2:25 PM, in the administration office, he was asked if employees should report alleged abuse immediately. He stated, "Yes, anytime there is an allegation of abuse, it should be reported and investigated immediately. It is in our policy ..."

Interview with the Respiratory Therapy Director on 10/1/18 at 2:47 PM, she was asked when she was notified of the allegation of abuse. She confirmed that Witness #1 called her on the telephone and let her know what she had observed and what she had heard. The Respiratory Therapy Director asked Witness #1 to send an email detailing the incident. The Respiratory Therapy Director stated, "I asked Witness #1 if she thought RN #1 was going to do harm. She said that he [Resident #1] had a tear and watery eyes but that he had those emotions sometimes and she wasn't sure. Witness #1 further stated to me that she had concerns because she felt he [RN #1] was inappropriate. I escalated it to [Named Intensive Care Unit [ICU] Manager], his direct manager through email that day [September 3, 2018] ..."
The Respiratory Therapy Director was asked what was the expectation of staff when they see or hear alleged abuse. She stated, "The expectation was to report sooner. Her [Witness #1] response was she didn't want to have conflict with the nurse [RN #1]. I let her know it should have been reported immediately ..."

Interview with the ICU Nurse Manager on 10/1/18 at 3:06 PM in the administrative office, she was asked when she was made aware of the allegation and what actions did she take. She stated, "I was notified by email ...on September 4. I wasn't here on Monday it was Labor Day. It was an active investigation. I talked with him [RN #1] on Tuesday September 4, 2018 on the phone, and concerns about inappropriate talking to a patient. He said he never said anything inappropriate. He and [Named Patient #1] got along ..." The Nurse Manager was asked who made the decision to terminate him. She stated, "As a group, the CNO, HR, myself and the Director of ICU made the decision to terminate him. RN #1 ' s response was he did not cause harm to the patient but he did raise his voice to the patient. He stated he is ex-Navy and he has a loud voice.

Interview with the Administrative Director Clinical Quality Improvement on 10/1/18 at 3:53 PM, in the administrative office, she was asked if the facility regularly monitors and audits staff and patients for concerns. She stated, "We have leadership rounds. Every director had a 4 room minimum. There is 1 person that does rounds on the weekends ...In ICU, the Director and the Nurse Manager do the rounds. I checked with them and there is nothing documented ..."
Interview with the Chief Nursing Officer (CNO) in the administrative office on 10/1/18 at 4:25 PM, she stated, "...In this case, it was presented to me that they saw it as unprofessional behavior...We reported it. Should they have picked up the phone - yes, but they weren't thinking abuse..."

A telephone interview with RN #1 on 10/3/18 at 5:05 PM, RN #1 was asked to verify his written statement. RN #1 verified the statement was accurate and confirmed he wrote it on 9/7/18. He was then asked to describe the interaction with Patient #1. RN #1 stated, "First of all, the person that made the accusation, she don't like me, I don't like her and this isn't the first time that we've had difficulty ...I don't beat on patients, I've never hit a patient ...I did not hit [Named Patient #1]. When he pulled his trach [tracheostomy cuff] out, I had another male nurse come in there and help ...I told my boss ...she called me on a Tuesday [9/4/18] morning and I done worked 3 days in a row and evidently she thought I was going to run right back over there and I didn't. I came in Friday [9/7/18] morning. I told her when she called initially, I said I'm about sick of you guys, I said I didn't do anything to [Named Patient #1]..."
He was asked if anyone was in the room with him, RN #1 stated, "No, no one was in the room with me, but I had the curtain open because he was a difficult patient ...and toward the end of the shift, he peed and when I turned him on his side up against the side rails, I was to his back trying to put the new sheets and stuff under him, that's the only thing that I can think that maybe he thought I had him pushed up to the side rails ...I mean you literally had to kinda manhandle him because he would throw his legs over the side rails and stuff, I don't mean like mistreating manhandling him, I mean you know you got to be kinda forceful with him, otherwise he is going to take over". RN #1 was asked if Patient #1 was a tearful man and did he cry a lot. RN #1 stated, "No, no, no, no, no, no ...I told my boss I don't know what she told you guys, but I can tell you right now that was a lie and I did not mistreat him ...He's not that bad of a patient, it's just you know, he gets a little crazy, they had him on [Named Antipsychotic medication] because he could get buck wild and start pulling everything, try to pull his trach out and throwing his legs over the side rails and stuff like that ..."
He was asked if Patient #1 was restrained. RN #1 stated, "One side, one of his wrists, I untied it when I was changing his sheets, I rolled him one way and then the other way ..."
He was asked if he worked any more shifts between the night of the alleged abuse allegation and when he was terminated. He stated, " ...It happened on the 28th [August] and [Named Boss] called me on the morning of 4th, on Tuesday morning ...kinda what made me mad was if it happened on the 28th, why are you just calling me when I'm getting off work from working 3 days in a row ...and I came in that Friday [Sept. 7th] and that's when she said I was suspended for 3 days pending an investigation ...they called me Monday the 10th [September] and said we've done our investigation and we're going to terminate you ...and they wanted to see me the next day which was Tuesday [9/11/18] ...But I'm telling you here and now I did not touch him ...half of the nurses up here curse, I ' m not saying I cursed the patient and stuff, when I came out I might have said I'm about sick of taking care of [Named Patient #1's] ass outside the room about 6:30 AM ...When I had him rolled over changing his sheets and he was on his left side, his right arm was not restrained and that's when he reached up and pulled his trach out. I hollered somebody come help me and the other nurse came in and that's when we called Respiratory and had them come put his trach back in. I told [Named Doctor] about it, he said just leave it out and put a piece of tape over it, but they had already put one in, I told him he's been a royal wild man tonight, something to that nature."

A telephone interview with Witness #3 on 10/3/18 at 6:18 PM, he stated his emailed statement was accurate and described what he heard. He stated, " ...I can't quote because it's hard to remember exactly what RN #1 said, but just remember he got up and said, excuse my French, I'm just going to be direct. Umm, he [RN #1] said, "Damn it, what are you trying to do hurt yourself" and he went back in there [Resident #1 ' s room]...I recall that he had a momentary lack of professionalism at the bedside. That was about the extent that I was around for."
Witness #3 was asked if RN #1 was in the hall or the bedroom when he made the comment about hurting himself to Resident #1. Witness #3 stated, "I believe he was entering the bedroom."
Witness #3 was asked if he felt this was an abusive situation. Witness #3 stated, "...I believe he needed to be reminded to maintain professionalism at the bedside ..."

A telephone interview with Witness #1 on 10/4/18 at 9:11 AM, Witness #1 stated her emailed statement was accurate and described the incident. Witness #1 stated, " ...It's on the policy to report immediately. My boss called me in and told me that. I didn't think abuse, it didn't register with me. I thought it was inappropriate, you don't treat people that way ..." Witness #1 was asked if she felt he had been abused in any way. Witness #1 stated, "Yeah, maybe emotionally with the woman comments ..."

The hospital failed to immediately report and respond to an allegation of abuse to ensure all the patients were protected, and measures were implemented to ensure patients were free from further potential abuse when RN #1 was not immediately suspended and worked an additional three 12 hour shifts before being suspended pending an investigation.