HospitalInspections.org

Based on interview, record review and policy review, the hospital failed to ensure a safe environment when they allowed one staff member (Staff HHHH), who had been accused of abuse, to care for five discharged patients (#37, #38, #39, #40 and #41), prior to the completion of an investigation. This failed practice placed all patients at risk for their safety.

This failed practice resulted in a systemic failure and noncompliance with 42 CFR 482.13 Condition of Participation: Patient's Rights. The hospital census was 384.

Based on interview, record review and policy review, the hospital failed to ensure a safe environment when they allowed one staff member (Staff HHHH), who had been accused of abuse, to care for five discharged patients (#37, #38, #39, #40 and #41), prior to the completion of an investigation. This failed practice placed all patients at risk for their safety.

Findings included:

Review of the hospital's policy titled, "Abusive Behavior, HR-001," dated 07/14/22, showed that abusive behavior (whether physical, verbal, mental, sexual or neglectful) by any employee toward a patient will not be tolerated. The manager/supervisor upon a report of possible patient abuse or neglect by an employee will suspend the suspected employee pending investigation. If the allegation is substantiated or a pattern of such allegations is established, the employee will be terminated.

Review of the hospital's document titled, "230160285," dated 05/16/23, showed the following:
The incident occurred on 05/12/23 and was reported to a physician by Patient #12's daughter on 05/13/23. Patient #12 felt uncomfortable when Staff HHHH, Registered Nurse (RN), listened to her heart. He touched places on her breast that she did not feel were appropriate if he was only listening to her heart and lungs. She called her daughter and told her what happened.

Review of the hospital's undated and untitled document showed Staff HHHH, RN, worked from 6:46 PM on 05/14/23 to 7:45 AM on 05/15/23.

Review of the hospital's document titled, "East 7 Assignments," dated 05/14/23, showed Staff HHHH, RN, was assigned to care for Patients #37, #38, #39, #40 and #41.

Review of Patient #12's medical record showed the following:
- She was a 62-year-old female who was admitted on 05/09/23 for abdominal pain.
- On 05/12/23 at 9:00 PM, Staff HHHH, RN, documented that Patient #12's heart beat was regular, her lung sounds were normal and her abdomen was soft, flat, and had audible bowel sounds.
- On 05/13/23 at 4:53 PM, a nursing note showed that Patient #12 was alert and oriented times four (A&O x 4, a person is oriented to person, place, time, and situation) and she was transferred to the first floor.
- On 05/16/23, Patient #12 was discharged home.

During an interview on 10/26/23 at 1:10 PM, Staff TTT, Nurse Manager, stated that it was the expectation to remove staff from patient care while they were under investigation.

During an interview on 10/26/23 at 1:22 PM, Staff SSS, Risk Management Director, stated that when allegations of abuse were reported against a staff member (alleged perpetrator), the individual was removed from all patient care.

During an interview on 10/26/23 at 1:35 PM, Staff C, CNO, stated that when allegations of abuse were reported against a staff member (alleged perpetrator), the intent was to immediately pull that staff member from patient care.