HospitalInspections.org

Based on medical record review, document review, policy review, and interview, the facility failed to ensure all patients are free from all forms of abuse, neglect, and harassment for 1 of 20 patients (Patient #1). Specifically, facility staff failed to ensure Patient #1 was assessed by a medical provider following their allegation of abuse and the facility staff failed to report Patient #1's allegation of abuse per facility policy.

Findings include:

Review of policy "Patient Abuse Policy," last revised February 2024, revealed "Hospital team members will report suspected instances of physical abuse, mistreatment and neglect of hospital patients in accordance with the Patient Abuse Reporting Law (Public Health Law Section 2803-d). All incidents must be reported immediately to the Department Manager or designee and Administration for appropriate investigation and follow up. For situations involving non-employees, contact Security. Any patient who is suspected of, or who has reported being abused or mistreated will be assessed by a Physician, Resident, or Advanced Practice Provider immediately. Refusals should be documented in the Medical Record. The suspected abuse will be entered in the safety event reporting system. Further investigation and follow-up will be coordinated by the Department Manager and the appropriate administrator for the area. The staff in the Risk Management Department will assist with the investigation and follow-up. RRH (Rochester Regional Health) Clinical and/or Operational leadership will report substantiated incidents to the New York State Department of Health, or licensing entities, when required. A root cause analysis will be conducted on all serious incidents."

Review of policy "Event Reporting Procedure", last reviewed November 2023, revealed "All employees/staff are responsible for identification and notification of any errors, close calls or other safety events to their supervisor/manager. Errors, close calls, and other safety events are reported in the on-line event reporting system by any staff member as soon as possible, but ideally no later than 24 hours after event discovery. Provider/Nurse Manager/Supervisor will: ensure those involved in the error, close call, or other event are assessed for injury or harm, are safe and that emergent medical care is provided as indicated by the incident; Ensure necessary immediate actions/interventions are taken to prevent additional error/close call. For patient events, notify the attending physician or provider most closely associated with the error/close call; Ensure that appropriate clinically relevant documentation of the incident is entered in the medical record of all patients involved or impacted by the incident. However, do not record in the medical record that a safety event was entered in the event reporting system. Appropriate follow up should focus on the impact of the event and what was done to minimize the likelihood that the incident will reoccur. This should include the following elements: An explanation of the circumstances surrounding the event; An updated assessment of the effects of the incident on the patient; A summary of current patient status including follow up care provided and post incident diagnosis; A chronology of steps taken to investigate the incident that identifies the date(s) and person(s) or committee(s) involved in each review activity; The identification of all findings and conclusions associated with the review of the incident; A summary of all actions taken to correct identified problems, to prevent recurrence of the incident and/or to improve overall patient care. It is the director's ultimate responsibility to ensure thorough and timely follow up for events in his/her assigned areas".

Review on 08/03/24 of "Mandatory Compliance Education Core Content", dated 01/2023, revealed the annual education includes a section on reporting incidents. Staff are educated on using the facility's online event reporting process to report incidents which include but is not limited to alleged assaultive behaviors. Depending on the nature of the event, different degrees of investigation will be conducted. If an error causes serious harm, it may be considered a Serious Safety Event. A Serious Safety Event is thoroughly reviewed to identify the root cause of the error, and to identify actions that impact processes and systems for improvement. The results of Serious Safety Event investigations are reported internally to Quality Committees and Boards, and externally to federal and state regulatory agencies as needed. Safety events should be entered into the online reporting system as soon as possible, but no later than 24 hours after event
discovery.

Review on 07/31/24 of Patient #1's medical record, dated 07/10/24 to present, revealed:
-On 07/21/24 at 02:28 AM, Staff (H), Registered Nurse, note revealed "interpreters from the contracted interpretation services set up to come back again tomorrow morning from 08:00 AM to 12:00 PM. Patient #1 also stating they were "abused" by a community contracted interpreter (Staff V). Patient #1 claiming an interpreter was holding their hands so that they could not sign, and the interpreter was not letting people in or out of the room."
-On 7/21/24 at 10:26 AM, Staff (HH), Psychiatrist, note revealed Patient #1 "reports that they have been mistreated by tactile sign interpreter while admitted in the hospital, states that the interpreter (Staff V) held their hand and prevented them from expressing themselves."
-On 7/21/24 at 06:43 PM, Staff (K), Registered Nurse, uploaded a picture of Patient #1's left wrist with a title of "bruising to left wrist." The photo shows a faint blush circular area is noted on the outer aspect of Patient #1 wrist. There are several other light blue and red markings on Patient #1's wrist and top of hand. An intravenous catheter is noted on Patient #1's upper forearm. There is no way to determine the exact cause of the discolorations.
-On 7/21/24 at 07:44 PM, Staff (K), Registered Nurse, note revealed the contracted interpretation services interpreter on the floor.

There is no documented evidence in Patient #1's medical record that they were assessed by a provider following their allegation of abuse.

Review on 08/01/24 of facility adverse event reports from 07/2024 to present revealed no evidence Patient #1's allegation of abuse was reported.

Interview on 07/31/24 at 11:57 AM with Staff (J), 2800 Nurse Manager, and Staff (L), Director of Nursing, revealed Patient #1 started to complain around 07/20/24 that Staff (W), community contracted Tactile Interpreter, assaulted Patient #1. Both Staff (J) and Staff (L) went to speak to Patient #1 on 07/22/24. Patient #1 did not describe physical abuse. However, Patient #1 stated the assault by Staff (W) consisted of Staff (W) taking Patient #1's voice by holding Patient #1's hands to prevent signing, Staff (W) prevented Patient #1 from leaving the hospital room during the day, and Staff (W) was misinterpreting for Patient #1. Staff (J) and Staff (L) stated there was no bruising noticed on Patient #1's wrists. Staff (L) stated no incident report was entered into the hospital system regarding the assault allegation.

Interview on 07/31/24 at 02:00 PM with Staff (F), Interpreter Services Manager, revealed they were not aware of an allegation of an interpreter not letting a provider in Patient #1's room. Staff (F) stated an e-mail was received by Patient #1 alleging abuse from the interpreter. Staff (V) was immediately removed from Patient #1's interpretive service and Staff (F) spoke with the first interpreting company letting them know an accusation was made to which the interpreters said that did not happen. Staff (F) stated no incident report was placed. The event was reported to Staff (J), 2800 Nurse Manager, and Staff (L), Director of Nursing, met with the patient the following Monday.

Interview on 07/31/24 at 01:30 PM with Staff (K), Registered Nurse, revealed an e-mail was sent to Staff (J), 2800 Nurse Manager, regarding the incident.

Interviews on 07/31/24 at 02:30 PM with Staff (N), Registered Nurse and Staff (O), Registered Nurse, at 02:35 PM with Staff (Q), Registered Nurse, and Staff (R), Registered Nurse, and at 02:51 PM with Staff (I), Registered Nurse, revealed if there was an abuse allegation made by a patient, the allegation would be reported to the state, to the nurse manager, and the allegation would be reported in the Safe Connect system where they enter events such an abuse allegation. Additionally, a nursing assessment would be done, pictures could be taken, and security involvement if needed.

Interview on 08/02/24 at 10:00 AM with Staff (HH), Psychiatrist, revealed Staff (HH) stated there was no escalation or reporting of the abuse allegation of holding Patient #1's hands because it was so brief and only lasted a few seconds. If there was a suspicion of abuse, Staff (HH) stated it would be reported to supervision and the attending provider. Staff (HH) stated that if there was a suspicion of abuse, Staff (HH) stated it would be reported to supervision and the attending provider. Staff (HH) stated they did not make an incident report regarding Patient #1's abuse allegation.

Interview on 08/01/24 at 10:34 AM with Staff (B), Senior Director Regulatory Compliance, revealed there should have been a reported event entered into the hospital system when the allegations of abuse were heard by staff. Staff (B) stated there was an event placed on 07/31/24 for the bruising noted to Patient #1. Staff (B) stated Staff (L), Director of Nursing went to speak with Patient #1 after there was an allegation of an interpreter raping Patient #1. Patient #1 told Staff (L) the rape allegation was a typo so there was no concern regarding that allegation and there was no incident report made for the rape allegation.

Review on 07/31/24 of Staff (K), Registered Nurse, email dated 07/21/24 at 08:56 PM to Staff (J), Nurse Manager, revealed that Staff (K) spent at least eight hours in Patient #1's room today (07/21/24) talking with Patient #1, the interpreters and Patient #1's friend, trying to calm Patient #1 down, trying to relieve Patient #1's anxiety, and trying to coordinate interpreter services. Staff (K) wrote "want you (Staff J) to know that the friend that came up, is calling the for peoples with disabilities to report abuse by an interpreter that the patient (Patient #1) had earlier stated, not sure how early was, don't know if it was Friday or earlier in the week." An interpreter "grabbed their (Patient #1) hands and held them super tight basically cutting off their (Patient #1's) communication. The friend also said that this interpreter declined having the doctors come in and speak with them (Patient #1) and reported that they (Patient #1) did not want fellows or other people that were training to be in the patient's (Patient #1's) room, which the patient (Patient #1) never said, and they (Patient #1) feels like that person didn't properly interpret things that the providers were trying to tell them." Staff (K) emailed that they "did tell the patient that I (Staff (K)) was going to email you (Staff J) regarding issues with the interpreters."

Interview on 08/02/24 at 10:00 AM with Staff (A), Clinical Regulatory Compliance Specialist, and Staff (B), Senior Director Regulator Compliance, confirmed these findings.