HospitalInspections.org

Based on document review and interview it was determined that for 1 of 1 (Pt. #1) patient records reviewed for abuse allegations the Hospital failed to ensure that patients were free from all forms of abuse by failing to conduct a thorough investigation into allegations of staff to patient abuse.

Findings include:

1. On 11/2/2021, the Hospital's policy titled, "Response to Allegation of Abuse or Neglect on Hospital Premises" (July 2020) was reviewed. The policy required, " ...V. Procedure ...6. Investigation: After receiving an allegation of abuse or neglect occurring on hospital premises, an internal investigation is initiated by manager, executive leadership, and Patient Safety Department in collaboration with other departments as deemed necessary, and completed as quickly as possible."

2. On 11/2/2021, Pt. #1's clinical record was reviewed. Pt. #1 was admitted on 9/3/2021 with a diagnosis of Cerebral Vascular Accident (stroke). Pt. #1 was discharged on 10/1/2021.

3. On 11/2/2021, the patient relations worksheet was reviewed. The worksheet documented a nursing care grievance from Pt. #1. The grievance dated 9/13/2021, included, "Pt. [Pt. #1] informed me that CNA last night, [CNA name], acted disrespectful towards her. Says she [CNA] had an attitude the entire shift. Pt. [Pt. #1] also told me she has previously told her how to handle her when repositioning in the bed and during hoyer transfers and the CNA continued to pull on her neck." On 9/14//2021, there is email documentation that Pt. #1 reported "mistreatment and rude interactions from our staff...[Pt. #1] stated staff is rough with her. Forcefully pulling on her l (left) leg and grabbing her by her neck during transfers ....Some of the quotes mentioned to me that came from the patient [Pt. #1] were hard to believe. 'dead weight' and 'I only have to turn every 2 hours, not every two minutes." The patient relations worksheet included documentation on 9/22/2021, 9/23/2021, and 9/27/2021, of conversations with Pt. #1 and family, but lacked documentation of an investigation into the allegation.

4. The Facility did not provide documentation of an investigation regarding Pt. #1's abuse allegations against staff on 9/13/2021.

5. On 11/2/2021 at 10:52 AM, an interview was conducted with the Nursing Unit Manager (E #4). E #4 stated that she received a report that Pt. #1 reported that a staff member grabbed her by her neck. E #4 stated that she (E #4) was not able to identify what staff member Pt. #1 was accusing of grabbing her by the neck because the name provided by Pt. #1 was not a staff member. E #4 she that she could not substantiate Pt. #1's complaint. E #4 stated that Pt. #1 remained as an inpatient, the complaints were handled throughout Pt. #1's stay and no further complaints or allegation of staff mistreatment were received.

6. On 11/2/2021 at 11:48 AM, an interview was conducted with a Registered Nurse (E #5). E #5 stated that she overheard Pt. #1 talking to her roommate complaining about the staff grabbing her by the neck. E #5 stated that she did not document or report Pt. #1's complaint to anyone.

7. On 11/2/2021 at 12:28 PM, an interview was conducted with the Executive Director of Quality Regulatory/Performance Improvement/Patient Safety (E #7). E #7 stated that any actions taken regarding Pt. #1's complaint or grievance would be documented on the Midas form (patient relations worksheet). E #7 stated that she is not sure if an investigation was conducted to address Pt. #1's complaint of staff grabbing her by the neck because there is no documentation of an investigation. E #7 stated that Pt. #1's complaint/grievance was not reported as an abuse allegation.

8. On 11/3/2021 at 11:35 AM, an interview was conducted with a Nurse Supervisor (E #14). E #14 stated that Pt. #1's family reported the allegations. E #14 stated that Pt. #1 complained that she felt choked when a staff member grabbed her neck during a transfer and staff was being rude. E #14 stated that he conducted an investigation and informed the Nurse Unit Manager that there were no findings. E #14 stated that he (E #14) interviewed staff who took care of Pt. #1 from two days prior to the complaint, but did not document the interviews. E #14 stated that the allegations were not investigated as abuse and that he knows the staff would not intentionally choke a patient.

Based on document review and interview, it was determined that for 1 of 2 patient records (Pt. #3) reviewed for blood transfusions, the Hospital failed to ensure that vitals signs were monitored and documentation of the blood transfusion was completed in accordance with approved policies and procedures.

Findings include:

1. The Hospital's policy titled, "Blood Product Administration & Management of Blood Transfusion Reactions" (revised 3/2021), was reviewed on 11/2/2021 and required, "During a transfusion, the patient is observed for signs and symptoms that may indicate a blood transfusion reaction. Vital signs are taken pre-transfusion, within 15 minutes after the blood enters the vein, hourly throughout the transfusion and post-transfusion..."

2. The clinical record of Pt. #3 was reviewed on 11/2/2021. Pt. #3 was admitted on 5/20/2021, with a diagnosis of anoxic (lack of oxygen) brain damage. Pt. #3 had orders, dated 5/26/2021, to transfuse 2 units of red blood cells (PRBCs). The record indicated that the first PRBC unit transfusion was started at 4:40 PM by a Registered Nurse (E#10). The Nurse's (E#10) note, dated 5/26/2021 at 6:31 PM included, "...2x PRBCs transfused and tolerated well..." The record lacked documentation of any vital signs taken during the transfusions.

3. An interview was conducted with the System Nurse Informatics Coordinator (E#8) with the Interim Director of Nursing (E#9) present. Both stated after reviewing the policy, that vitals should be taken before transfusion is started, within 15 minutes after the start of the transfusion, hourly during the transfusion, and post transfusion. E#8 could not find any documentation of vital signs during Pt. #3's transfusions on 5/26/2021.

4. An interview was conducted with Executive Director of Quality Regulatory/Performance Improvement/Patient Safety (E#7) on 11/3/2021, at approximately 12:50 PM. E#7 stated that there was no documentation of the blood transfusion that Pt. #3 received on 5/26/2021. E#7 stated that per the nursing supervisor the blood was transfused during a dialysis treatment and there was some confusion as to who should document the transfusion record and monitoring. E#7 stated that there should have been a Midas (Patient Safety Event) report filed for this incident; however, confirmed that no report was filed.