HospitalInspections.org

Based on interviews, record review and policy review, the facility failed to develop a written procedure or policy to adequately investigate allegations of abuse, neglect or mistreatment to include methods to protect patients from abuse during investigations of allegations. These failures had the potential to place all patients admitted to the facility at risk for their safety from abuse or neglect by staff. The facility census was 34.

Findings included:

1. Record review of the Federal requirements set forth in the Medicare Conditions of Participation 482.13(c)(3), dated 10/17/08, showed that the hospital must ensure a timely, thorough and objective investigation of all allegations of abuse, neglect or mistreatment.

On 12/14/17, upon request, the facility was unable to provide an investigation process and/or policy.

During an interview on 12/14/17 at 10:00 AM, Staff J, Human Resources Administration Officer, stated that she was unaware of any policies regarding abuse and neglect investigations.

During an interview on 12/14/17 at 10:05 AM, Staff M, Quality Supervisor, stated that no one reviews the video on a regular basis and she did not have a policy for the investigative process.

During an interview on 12/14/17 at 10:15 AM, Staff A, Behavioral Health Unit Program Director, stated that in their training there was a section to teach staff awareness of self-care and to remove themselves from situations and she was unaware of any policy regarding investigations.

During an interview on 12/14/17 at 10:30 AM, Staff K, Safety Director, stated that the video of all of the hallways in the hospital can be saved for one week and he did not know of any process for the investigation.

During an interview on 12/14/17 at 11:28 AM, Staff N, Chief Nursing Officer, stated that he was unaware that they did not have a policy or procedure for investigating and reporting abuse and neglect.