HospitalInspections.org

Based on staff interviews and record review the facility failed to assure timely reporting to the appropriate State Agency (SA), as stated in VSA Title 33, Chapter 69, of an allegation of patient mistreatment by staff. (Patient #1). Findings include:

Per VSA Title 33, Chapter 69, ? 6903. Reporting suspected abuse, neglect, and exploitation of vulnerable adults
(a) Any of the following, other than a crisis worker acting pursuant to 12 V.S.A. ? 1614, who knows of or has received information of abuse, neglect, or exploitation of a vulnerable adult or who has reason to suspect that any vulnerable adult has been abused, neglected, or exploited shall report or cause a report to be made in accordance with the provisions of section 6904 of this title within 48 hours:
Per record review, conducted on 11/12/13, Patient #1 had a Patient Progress Note, written by MHW #1 and dated 8/4/13, that stated the patient had "asked to speak with this writer at the start of shift. [S/he] expressed some paranoid thoughts about a male RN on the night shift..."
During interview, at 2:31 PM on 11/12/13, MHW #1 stated that Patient #1 had requested to talk with the MHW on 8/4/13. The MHW stated that the patient's conversation had been "a bit disjointed", which the MHW stated was usual for the patient. The patient reportedly told MHW #1 that s/he was remembering a night nurse being on top of him/her, and the patient gave a fairly specific description of who the night nurse was. The MHW also stated that the information from the patient was fragmented and s/he felt the patient's thoughts were based in paranoia and delusion. MHW #1 then reported what Patient #1 had said to RN #1. The MHW further stated that s/he had not made any report to the SA and had not been aware that s/he was obligated to either report or cause a report to be made to the SA regarding allegations of mistreatment
Per interview, on 11/12/13 at 12:33 PM and 1:26 PM, respectively, both RN #1 and the RN Clinical Leader confirmed that MHW #1 had reported to them, on 8/4/13, that Patient #1 had expressed some paranoid thoughts about inappropriate interactions with a night nurse. Both staff members confirmed a report had not been made to the SA at that time.
The Nurse Manager stated during interview at 10:19 AM on 11/12/13, that s/he had not been made aware of the incident in which Patient #1 had alleged inappropriate treatment by a staff member until 8/9/13, at which time it was reported to the state agency.

Based on record review and confirmed through staff interviews the facility failed to assure that care and services were provided in accordance with established Policies and Procedures regarding; reporting of Abuse, Neglect and Exploitation and completion of event reports. (Patients #1 and #3). Findings include:

Per review, the facility policy, titled SB - Prevention of Abuse and Neglect of Patients by Staff of Springfield Medical Care Systems, dated 6/13/13, stated: E. Identification and Reporting of Abuse, Neglect, or Misappropriation of Property; 1. Identification by a Staff Member - "Any employee of Springfield Hospital has the right and the duty to report suspected incidents of abuse, neglect, mistreatment of patient or misappropriation of property of hospital patients. If any staff member knows of, or has received information of abuse neglect, mistreatment of a patient or misappropriation of their property, or has reason to suspect that a patient is being or has been, either physically or verbally abused by anyone (including family members, other patients, or visitors) or witnesses theft, the incident should be reported immediately. 2. How to Report - All incidents at Springfield Hospital should be reported to the Administrator and in the Event Reporting System. Reports need to be made to one of the Co-Directors at the Windham Center...4. Reporting to the State - A report must be made to Adult Protective Services within 48 hours of the incident."

The Event Reporting and Management Policy, dated 6/24/09 stated; ".....Event reporting is a means to assess and improve organizational process and provide a safe environment for patient care." The policy also stated; "...All medically relevant events should be documented in the patient's record including a description of the event, the time of the event, all actions taken (ex. Evaluation in the ED, notification of the attending physician, diagnostic procedures and treatment performed), and the results of interventions." Under Responsibilities: "....Reports are to be completed promptly on the day of the event occurrence. Late reporting is allowed though timely reporting is expected." The Event Reporting Procedure, dated 4/29/09, states; "Responsibility: The person who discovers, witnesses, or to whom the event is reported should complete an electronic event report...."

1. Per record review, conducted on 11/12/13, Patient #1 had a Patient Progress Note, written by MHW #1 and dated 8/4/13, that stated the patient had "asked to speak with this writer at the start of shift. [S/he] expressed some paranoid thoughts about a male RN on the night shift..."
During interview, at 2:31 PM on 11/12/13, MHW #1 stated that Patient #1 had requested to talk with the MHW on 8/4/13 and the patient's conversation had been "a bit disjointed", which the MHW stated was usual for the patient. The patient reportedly told MHW #1 that s/he was remembering a night nurse being on top of him/her, and the patient gave a fairly specific description of who the night nurse was. The MHW also stated that the information from the patient was fragmented and s/he felt the patient's thoughts were based in paranoia. The MHW stated s/he informed the patient that s/he was going to report the patient's concerns to the doctor and the patient expressed anger and said s/he didn't want the MHW telling his/her secrets. MHW #1 then reported the information to RN #1. MHW #1 further stated that s/he had not made any report to the SA and had not been aware that s/he was obligated to either report or cause a report to be made to the SA regarding allegations of mistreatment
Per interview, on 11/12/13 at 12:33 PM and 1:26 PM, respectively, both the RN Clinical Leader and RN #1 confirmed that MHW #1 had reported to them, on 8/4/13, that Patient #1 had expressed some paranoid thoughts about interactions with a night nurse, and the issue had then been discussed by the Treatment Team. Both staff members confirmed a report had not been made to the SA at that time.
The Nurse Manager stated during interview at 2:59 PM on 11/12/13, that s/he had not been made aware of the incident in which Patient #1 had alleged inappropriate treatment by a staff member until 8/9/13, at which time an event report was completed and the event was reported to the SA. The Nurse Manager further confirmed that staff did not, but should have, reported the incident within 48 hours of becoming aware of it, in accordance with the facility's established policies and procedures, and should have completed an event report.
2. Per review, on 11/12/13, a Physician had ordered " Benadryl 100 mg. orally now" on 11/8/13 at 7:50 AM for Patient #3. The rationale for the order states "anaphylactic reaction mushrooms". A repeat order for "Benadryl 100 mg orally x1 now" was ordered at 11/8/13 at 10:10 AM. However, per review of Patient # 3's Progress Notes for 11/8/13, nursing staff failed to document the events associated with Patient # 3's reaction to mushrooms to include evidence of vital signs, physical presentation during the reaction, response to the Benadryl administered.

During interview, on the afternoon of 11/13/13, the Nurse Manager confirmed that documentation regarding Patient #3's allergic reaction had not been completed and also confirmed that no event report had been completed in accordance with established policies and procedures.

Based on record review and confirmed through staff interviews nursing staff failed to evaluate the ongoing care needs for 1 patient for whom a change in condition had occurred. (Patient #1). Findings include:

Per record review, conducted on 11/12/13, Patient #1 had a Daily Nursing Note, dated 8/5/13 at 7:03 PM, that stated "Complains of pain in [his/her] abdomen behind [his/her] belly button. [His/her] abdomen is noted to be distended and [his/her] belly button pushed out. S/he states s/he normally has a belly button that indents into [his/her] abdomen. States s/he feels as though there is something hard behind [his/her] belly button that is pushing it out. Will continue to monitor." Despite this assessment there was no evidence of any further evaluation of the condition for a period of two days. Subsequent nursing notes, dated 8/7/13 stated, at 5:47 PM, "....Also, continues to report that [his/her] abdomen is very tender and has been tender for a few days. It is noted to be distended. S/he reports that [his/her] umbilicus does not normally extrude but it is noted to be extruded currently due to abdominal distension." At 7:28 PM the nursing note stated: "Pt reports umbilical pain 6/10 that has been going on for 2 days.....states s/he has reported this to other nurses but nothing has been done." The patient underwent a medical evaluation at 11:08 AM on the morning of 8/8/13 and was diagnosed with an umbilical hernia.

During interview at 5:38 PM on 11/13/13, the Nurse Manager confirmed there was no evidence of ongoing nursing assessment for a period of 2 days following a change in the patient's condition.

Based on record review and confirmed through staff interviews the care plan for one patient had not been revised to reflect current status. (Patient #1). Findings include:

Per record review, conducted on 11/12/13, Patient #1 had a Daily Nursing Note, dated 8/5/13 at 7:03 PM, that stated "Complains of pain in [his/her] abdomen behind [his/her] belly button. [His/her] abdomen is noted to be distended and [his/her] belly button pushed out. S/he states s/he normally has a belly button that indents into [his/her] abdomen. States s/he feels as though there is something hard behind [his/her] belly button that is pushing it out. Will continue to monitor." Despite this assessment there was no evidence of any further assessment or evaluation for a period of two days. Subsequent nursing notes, dated 8/7/13 stated, at 5:47 PM, "....Also, continues to report that [his/her] abdomen is very tender and has been tender for a few days. It is noted to be distended. S/he reports that [his/her] umbilicus does not normally extrude but it is noted to be extruded currently due to abdominal distension." At 7:28 PM the nursing note stated: "Pt reports umbilical pain 6/10 that has been going on for 2 days.....states s/he has reported this to other nurses but nothing has been done." The patient underwent a medical evaluation at 11:08 AM on the morning of 8/8/13, was diagnosed with an umbilical hernia and the follow up plan included a recommendation that an abdominal CT scan be done at a future date. Per review the patient's care plan had not been revised to reflect the change in condition and current status.

During interview at 5:38 PM on 11/13/13, the Nurse Manager confirmed that Patient #1's care plan had not been revised to reflect his/her current status.

Based on interview and record review the nursing staff failed to complete documentation of an event involving a patient who experienced a food reaction. Patient #3 (Findings include)

Per review on 11/12/13 a Physician had ordered " Benadryl 100 mg. orally now" on 11/8/13 at 7:50 AM for Patient #3. The rationale for the order states "anaphylactic reaction mushrooms". A repeat order for "Benadryl 100 mg orally x1 now" was ordered at 11/8/13 at 10:10 AM. However, per review of Patient # 3's Progress Notes for 11/8/13, nursing staff failed to document the events associated with Patient # 3's reaction to mushrooms to include evidence of vital signs, physical presentation during the reaction, response to the Benadryl administered. Per interview on 11/12/13 at 4:35 PM, the Dietary Manager confirmed that although it was noted on Patient #3's dietary profile s/he had an allergy to mushrooms, another staff cook had served the patient on 11/8/13 an omelette with mushrooms. The clinical record also did not include circumstances associated with the food source.

During interview, on the afternoon of 11/13/13, the Nurse Manager confirmed the lack of documentation regarding Patient #3's allergic reaction and confirmed that no event report had been completed to date.

Based on staff interview and record review, nursing notes did not reflect an event regarding a food reaction experienced by 1 applicable patient nor did it describe the patient's response to treatment for the allergic reaction. (Patient #3) Findings include:

Per review on 11/12/13 a Physician had ordered " Benadryl 100 mg. orally now" on 11/8/13 at 7:50 AM for Patient #3. The rationale for the order states "anaphylactic reaction mushrooms". A repeat order for "Benadryl 100 mg orally x1 now" was ordered at 11/8/13 at 10:10 AM. However, per review of Patient # 3's Progress Notes for 11/8/13, nursing staff failed to document the events associated with Patient # 3's reaction to mushrooms to include evidence of vital signs, physical presentation during the reaction, response to the Benadryl administered. Per interview on 11/12/13 at 4:35 PM, the Dietary Manager confirmed that although it was noted on Patient #3's dietary profile s/he had an allergy to mushrooms, another staff cook had served the patient on 11/8/13 an omelette with mushrooms. The circumstances associated with the food source was also not documented.

During interview, on the afternoon of 11/13/13, the Nurse Manager confirmed the lack of documentation regarding Patient #3's allergic reaction and confirmed that no event report had been completed to date.

Based on record review and confirmed through staff interviews the facility failed to recognize opportunity for improvement and failed to address previously identified deficient practice related to staff knowledge of reporting requirements and food safety. Findings include:

1. Per record review, conducted on 11/12/13, Patient #1 had voiced concerns to MHW #1 on 8/4/13, regarding mistreatment by a staff nurse. Although the MHW notified the nurse in charge at the time, and although the RN Clinical Leader was made aware on that date, the information was not reported to the appropriate SA until 4 days later on 8/8/13.
The Nurse Manager stated, during interview at 2:59 PM on 11/12/13, that she became aware of the allegations made by Patient #1 against a staff nurse on 8/9/13 and had identified, at that time, that staff had not reported to the SA in a timely manner. Although the Nurse Manager had identified this deficient practice, and had spoken with staff involved regarding the late reporting of this incident, no further action had been taken to assure all staff were aware of reporting requirements, in an effort to assure like incidents did not recur.

2. Per record review on 11/12/13 a Physician had ordered "Benadryl 100 mg. orally now" on 11/8/13 at 7:50 AM for Patient #3. The rationale for the order states "anaphylactic reaction mushrooms". A repeat order for "Benadryl 100 mg orally x1 now" was ordered at 11/8/13 at 10:10 AM. However, per review of Patient # 3's Progress Notes for 11/8/13, nursing staff failed to document the events associated with Patient #3's reaction to mushrooms to include evidence of vital signs, physical presentation during the reaction, response to the Benadryl administered

During interview, at 4:37 PM on 11/12/13, the Dietary Manager stated that information regarding patient food allergies is documented on a dietary card and kept in the kitchen. S/he stated the process to assure patients do not have exposure to any known food allergen has been to not keep the food item in the kitchen. However, although Patient #3's allergy to mushrooms was documented, the patient ingested food, provided by dietary staff, containing mushrooms, resulting in an allergic reaction requiring medical intervention.
Despite the knowledge of this incident no action had been taken to assure all patients remained free from exposure to allergy causing food items.
The VP of Patient Care Services and the Nurse Manager both confirmed, during interview at 4:38 PM on 11/13/13, the lack of action taken to assure reporting requirements will be met by all staff and to assure patients will not ingest identified food allergens.