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Based on record review and interview, he facility failed to ensure all patients were free of abuse/neglect/harassment, in that,

the facility did not immediately act on the 8/05/2022 report of abuse/neglect of Patient #1 to protect that patient and other patients from Personnel #7.

Findings

Personnel #7 was allowed to continue to work the rest of her night shift 8/05/2022 (3 patient - Patient #1, Patient #2, and Patient #3) as well as subsequent night shifts on 8/06/2022 (3 patients - Patient #4, #5, and #6), and 8/07/2022 (3 patients - Patient #7, #8, and #9). The nurse was not suspended pending investigation until 8/11/2022.

The facility's 8/05/2022 report reflected, "8/05/2022 CVO (Constant Visual Observation) ordered at 17:11 when night shift PCT went to sit at 18:45 there was no CVO at bedside. Feces and urine observed all over the floor...there was no family or staff at bedside with him...CVO for line of sight...Observed Personnel #7 making statements to Patient #1...should be embarrassed to be in diapers...he was not sorry as he was not trying...it was his choice to be cold...nurse had no problem being mean...Witnesses Personnel #5, Personnel #6, Personnel #9...Delay in care; Emotional distress...spoke with Personnel #6 that night...verified the information provided in the report when providing their side of the story..."

The facility's 8/12/2022 report reflected, "PCT expressed concern about the care and communication provided by a nurse caring for a patient on unit D10 on the night of 8/05/2022...The involved nurse's manager shared that on 8/10 she interviewed the nurse who acknowledged several of the expressed concerns including leaving the patient on the bedside commode for over eleven hours. In addition the nurse acknowledged that she made statements to the patient surrounding shame in wearing a diaper...nurse was the boss...no problem being mean to the patient...Placed on administrative leave 8/11...allegation of neglect was substantiated..."

The facility staff (Four PCTs, 1 staff nurse, 2 Charge Nurses, and the House Supervisor) did not follow the facility procedure for "Escalate until Resolution" when abuse/neglect was reported on the night shift.

The facility did not investigate and report the abuse timely to the department. The facility report was on 8/05/2022. The facility notified the department on 8/15/2022.

During a telephone interview on 10/11/2022 at 2:14 PM, Personnel #2 was asked what Escalate to Resolution meant. Personnel #2 stated escalating issues up the chain to Charge, continue to Admin Supervisor/House Supervisor or Manager/Administrator on call until the resolution is found. Personnel #2 was asked if it was found that the Escalation to Resolution process had not been followed. Personnel #2 stated Yes, we did discuss that in our follow-up meeting.

During an interview in the conference room on 10/11/2022 ending at 2:33 PM, Personnel #1 was with Personnel #15. Personnel #1 was asked to confirm the abuse/neglect should have been reported within 48 hours. Personnel #1 stated yes ma'am. Personnel #1 was asked to confirm the policies had not been followed. Personnel #1 stated they were not.

The facility's 5/03/2019, effective "Child Abuse or Neglect: Assessment and Response" required, "All investigations will occur in a timely, thorough, and objective manner...considered a grievance...immediately report any allegation of abuse, neglect, unexplained injury or exploitation by an employee...to the patient's attending physician...Take immediate action to prohibit contact between the alleged abuser and any patients...shall make a report not later than the 48th hour after the hour the professional first suspects that the child has been or may have been abused or neglected..."

Based on record review and interview, the facility failed to ensure that data collected to identify opportunities for improvement had been implemented to effect changes that will lead to improvement, in that,

the facility failed to implement identified opportunities of improvement after investigating the 8/05/2022 abuse/neglect case of Personnel #7.

Findings

The facility's 8/05/2022 report reflected, "8/05/2022..Observed Personnel #7 making statements to Patient #1...should be embarrassed to be in diapers...he was not sorry as he was not trying...it was his choice to be cold...nurse had no problem being mean...Witnesses Personnel #5, Personnel #6, Personnel #9...Delay in care; Emotional distress...spoke with Personnel #6 that night...verified the information provided in the report when providing their side of the story..."

The facility's 8/12/2022 report reflected, "PCT expressed concern about the care and communication provided by a nurse caring for a patient on unit D10 on the night of 8/05/2022...The involved nurse's manager shared that on 8/10 she interviewed the nurse who acknowledged several of the expressed concerns including leaving the patient on the bedside commode for over eleven hours. In addition the nurse acknowledged that she made statements to the patient surrounding shame in wearing a diaper...nurse was the boss...no problem being mean to the patient...Placed on administrative leave 8/11...allegation of neglect was substantiated...Occurred on 8/05/2022...PCT had shared her concerns with her team leader...who spoke with the team leader of the D10 unit on 8/07/2022. These concerns were then osculated to the D10 Clinical Manager and vice President on 8/08/2022...Identified Opportunities...improve osculation real-time during the night shift and after the event...empower and encourage staff to osculate to the correct individuals and beyond when they feel the right actions are not being taken...Escalate to Resolution concept identified...implementation of the Constant Visual Observation Order as soon as it was ordered...following nurse policy for focused assessments...naso-gastric tube verification completed and documented...documentation for IV assessment, intake and output...Golytely kept in the Omnicell or better regulated..."

The facility's staff (Four PCTs, 2 staff nurse, 2 Charge Nurses, and the House Supervisor) did not follow the facility procedures for "Child Abuse or Neglect" and "Escalate until Resolution" when abuse/neglect was reported on the night shift.


During a telephone interview on 10/11/2022 at 2:14 PM, Personnel #2 was asked about follow-up or implementation. Personnel #2 stated I was not the direct leader - Personnel #3 was. Personnel #2 was asked what Escalate to Resolution meant. Personnel #2 stated escalating issues up the chain to Charge, continue to Admin Supervisor/House Supervisor or Manager/Administrator on call until the resolution is found. Personnel #2 was asked if it was found that the Escalation to Resolution process had not been followed. Personnel #2 stated Yes, we did discuss that in our follow-up meeting.

During an interview in the conference room on 10/11/2022 ending at 2:33 PM, Personnel #1 was with Personnel #15. Personnel #1 was asked to confirm the abuse/neglect should have been reported within 48 hours. Personnel #1 stated yes ma'am. Personnel #1 was asked to confirm there was no evidence of follow through with implementing the opportunities found during the investigation. Personnel #1 stated no, there was not. Personnel #1 was asked the facility notified the state that re-training and in-services occurred. Personnel #1 stated yes, that is what I was told happened. Personnel #1 stated I have no documented education post event. Personnel #1 was asked if there had been any no policy changed. Personnel #1 stated no. Personnel #1 was asked to confirm the policies had not been followed. Personnel #1 stated they were not.

The facility's 5/03/2019, effective "Child Abuse or Neglect: Assessment and Response" required, "All investigations will occur in a timely, thorough, and objective manner...considered a grievance...immediately report any allegation of abuse, neglect, unexplained injury or exploitation by an employee...to the patient's attending physician...Take immediate action to prohibit contact between the alleged abuser and any patients...shall make a report not later than the 48th hour after the hour the professional first suspects that the child has been or may have been abused or neglected..."