HospitalInspections.org

Based on interviews and document review, it was determined the facility staff failed to timely report an allegation of abuse as per mandated reporting requirements and failed to conduct an assessment to include documentation of the alleged injury for one (1) patient (Patient #2).

Findings:

On February 5, 2024, the surveyor conducted a medical record review for Patient #2 (P2).

That review revealed a nursing note from 10/05/2023 at 8:03 p.m. advising that the reason P2 is leaving the facility against medical advice (AMA) was due to facility staff holding the patient's arm during the patient's stay at the facility.

An admission health history completed by the physician on 10/04/2023 at 1:00 p.m. documented there were no skin abnormalities identified. There was no documentation in the health history of the allegation from P2. There was no other documentation in the medical record that staff assessed P2 for bruises or injuries after learning of the allegation of bruising by a staff member grabbing the patient's arm.

During a surveyor interview on February 5, 2024 at 12:48 p.m., Staff Member #2 (SM2) stated that (P2) told P2's parent that P2 was held on the wrist/arm by a staff member and the parent reported the allegation to the facility staff. SM2 stated that SM2 was notified on 10/04/2023 about the concern from P2's parent that P2 had bruises on P2's arm caused by a staff member grabbing P2's arm. SM2 spoke with P2 on 10/04/2024 at 4:00 p.m. to gather more information about the incident. SM2 stated that based on the information obtained from P2 and P2's parent, the alleged incident occurred on 10/04/2023 around 3:00 a.m. SM2 stated that child protective services was notified about the alleged incident on 10/06/2023 at 6:35 p.m., more than twenty-four (24) hours after the staff was made aware of the allegation.

A review of the facility's policy titled "Guidelines for Reporting of Suspected Neglect, Abuse, or Mistreatment of a Patient" approved 09/2022 states in part:
... Responsible Persons: All health care professionals are legally responsible for reporting all suspected child or adult/elder abuse neglect and exploitation and certain injuries from domestic violence....
1. Reporting Abuse or Neglect - Must be completed within [twenty-four] 24 hours of first knowledge of abuse....
... Mandated reporters directly involved in the care of the patient must report all suspected abuse, neglect, and exploitation of children, incapacitated adults and elders within 24 hours to the local welfare/social services agency of the county or city where the individual resides, or where the abuse is believed to have occurred.
... Guidelines:
The person required to make the report shall disclose all information which is the basis for his suspicion of abuse, neglect or exploitation.
... Documentation: Documentation in the medical record is essential in order to protect the patient and for the outcome of any legal case. Records should include, whenever possible:
1. Chief complaint and description of abusive even, using the patient's own words
2. Medical and social history
3. Detailed description of injuries, type, size, number, location, resolution, possible causes and explanations given. Use a body chart if needed or the State Physical Assessment form.

The above concerns were discussed with SM1, SM2, SM4, and SM6 at the exit conference on 02/05/2024 at 4:00 p.m.