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Based on policy review, review of North Carolina General Statute 10A NCAC 13O .0102, medical record review, internal document review, and staff interviews, the facility failed to notify the Health Care Personnel Registry (HCPR) of an allegation of staff to patient abuse. (Patient #21)

The findings included:

Review of facility policy "Abuse, Neglect and Human Trafficing: High Risk Indicators of and Access to Protective Services" revised 10/2018 revealed "....Abuse- is defined as "the willful infliction of physical pain, injusry or mental anguish, unreasonable confinement....1. All (named hospital) personnel will report suspected abuse or neglect of a child, adult or elderly person to the appropriate authorities..."

Review of NC General Statute 10A NCAC 13O .0102 revealed "The reporting by health care facilities to the Department of all allegations against health care personnel...should be done within 24 hours of the health care facility becoming aware of the allegation..."

Closed medical record review on 08/15/2019 of Patient #21 revealed a 14-year-old male presenting to the facility's emergency department under Involuntary Commitment on 11/17/2019 for self injurious behaviors. Review revealed the patient has a history of autism and developmental delays. Review revealed the patient remained in the emergency department waiting for bed placement until he was transferred on 01/04/2019.

Review of the internal investgation documents on 08/16/2019, revealed on 12/14/2018 "the director of the emergency department, was in the department at the end of the ED where Patient #21 room was. She saw named paramedic, was in the patient's room and saw him lunge at the patient and pushed him down on the bed by the throat. She yelled and named paramedic loosened his grip on the patient's neck..." Review of internal documents revealed on 12/19/2019 Risk Management Director contacted their legal department who recommended they follow their abuse and neglect policy. Review of documentaion revealed Child Protective Services and Department of Social Services were notified.

Interview with the Director of Human Resources on 08/15/2019 at 1330 revealed the named paramedic was taken off the schedule on 12/14/2019 and was terminated on 01/07/2019 after the investigation for "inappropriate behavior toward a patient." Interview revealed the video of the event was consistant with the internal documentation.

Review of the internal investgation documents on 08/16/2019, revealed on 12/14/2018 "the director of the emergency department, was in the department at the end of the ED where Patient #7 room was. She saw named paramedic, was in the patient's room and saw him lunge at the patient and pushed him down on the bed by the throat. She yelled and named paramedic loosened his grip on the patient's neck..." Review of internal documents revealed on 12/19/2019 Risk Management Director contacted their legal department who recommended they follow their abuse and neglect policy. Review of documentaion revealed Child Protective Services and Department of Social Services were notified.

Interview with the Director of Human Resources on 08/15/2019 at 1330 revealed the named paramedic was taken off the schedule on 12/14/2019 and was terminated on 01/07/2019 after the investigation for "inappropriate behavior toward a patient." Interview revealed the video of the event was consistant with the internal documentation.

Interview with the Director of Risk Managment on 08/15/2019 at 1345 revealed the incident was not reported within twenty-four hours to HCPR due to the recommendations from their legal department. Interiew confimed there was no filed internal incident or event report completed.

Interview on 08/15/2019 at 1045 with the DON (Director of Nursing), revealed Patient #21 was not on the list of adverse events provided. The DON confirmed the incident was not reported in the computer program.

Based on policy review, medical record review, and staff interviews, the facility staff failed to document patient response to restraint interventions used by failing to document debriefing of patients by staff for individuals placed in restraints resulting from violent or self-destructive behaviors. Review revealed documentation gaps in 2 of 3 patient charts reviewed (Patient #19, and Patient #20).

The findings included:

Review of the policy titled "Restraint of Patients" revised date 12/2016 revealed "PURPOSE: ...to provide guidance for preventing or managing restraint and seclusion so that patient health, safety, dignity, rights and well-being are optimized ...Documentation ...B ...each episode of restraint/seclusion use is to be recorded in the medical record. Documentation will include: ...debriefing of the patient with staff (violent/self-destructive) ..."

Review of the medical record revealed Patient #19 was a 16 year old female who presented to the facility's emergency department (ED) under involuntary commitment (IVC) hold on 08/06/2019 for aggressive and violent behaviors toward family members. Review of the record revealed Patient #19 was placed in 4 point restraints on 08/06/2019 at 2110 for aggression toward, and injury of staff after less restrictive interventions had failed. Review revealed the 4 point restraints were discontinued on 08/06/2019 at 2208 and Patient #19 was transferred to an outside acute psychiatric facility by law enforcement officers (LEO) on 08/08/2019. Review revealed no documented debriefing of Patient #19 after the restraint episode.

Interview on 08/16/2019 at 1445 during chart review with registered nurse (RN) #2 revealed there was no documentation indicating a debriefing had been done after Patient #19's restraint episode.

Interview on 08/16/2019 at 1530 with the Director of Nursing (DON) revealed "debrief is a conversation we have but we don't put it in the chart. That is something we will need to look into." Interview confirmed documentation of debriefing was missing from Patient #19's chart.

Review of the medical record revealed Patient #20 was a 36 year old female who presented to the facility's emergency department (ED) under involuntary commitment (IVC) hold on 07/06/2019 for aggressive and violent behaviors. Review of the record revealed Patient #20 was placed in 4 point restraints on 07/06/2019 at 1326 for aggression toward staff after less restrictive interventions had failed. Review revealed the 4 point restraints were discontinued on 07/06/2019 at 1720 and Patient #20 was transferred to an outside behavioral health facility by law enforcement officers (LEO) on 07/12/2019. Review revealed no documented debriefing of Patient #20 after the restraint episode.

Interview on 08/16/2019 at 1445 during chart review with registered nurse (RN) #2 revealed there was no documentation indicating a debriefing had been done after Patient #20's restraint episode.

Interview on 08/16/2019 at 1530 with the Director of Nursing (DON) revealed "debrief is a conversation we have but we don't put it in the chart. That is something we will need to look into." Interview confirmed documentation of debriefing was missing from Patient #20's chart.

Based on review of policy and procedures, Medical Staff Bylaws, Patient Safety & Clinical Quality minutes, Medical Executive Committee minutes, Board of Trustees minutes, and staff interviews, the facility staff failed to identify and track mortality and morbidity per facility policy.

The findings included:

Review on 08/16/2019 of the facility policy titled, "2019 Performance Improvement Plan- Patient Safety & Clinical Quality," last revised 03/2019, revealed " ...Reporting ...The Chief Executive Officer will report patient safety/clinical quality goals, strategies, and initiatives to the Medical Executive Committee (quarterly). The CEO [Chief Executive Officer] will also present the Patient Safety and Clinical Quality Performance Improvement Plan, including goals, strategies, and initiatives and an assessment of the program`s efficiency and effectiveness to the Board of Trustees and the Patient Safety and (named facility) oversight committee (annually) ..."

Review on 08/16/2019 of the facility`s "Medical Staff Bylaws," approved 10/17/2018, revealed ... "11.2 DEPARTMENTAL FUNCTIONS ...11.2(h) Review all deaths occurring in the Department and all unexpected patient care events and report findings to the MEC [Medical Executive Committee] ..."

Review on 08/17/2019 of the PSCQC [ Patient Safety & Clinical Quality] minutes, revealed no mortality or morbidity review from 05/2018 to present. The Quality Director was unable to provide any reference to mortality and morbidity within the PSCQC minutes from 05/2018 to present.

Review on 08/16/2019 of the MEC meeting minutes, revealed no reviews or mention of mortality and morbidity from 07/10/2018 through 06/11/2019.The Quality Director confirmed there were no reviews of mortality or morbidity in the MEC minutes from 07/10/2018 through 06/11/2019.

Review on 08/17/2019 of the Board of Trustees meeting minutes for 05/15/2018, revealed " ... [Named attendee] requested additional information on Review of Deaths from the PSCQC meeting." Review revealed no further reviews or updates were provided at any Board of Trustees meetings from 05/15/2018 to current. The Quality Director confirmed there were no reviews were in the minutes after 05/15/2018.

Interview on 08/14/2019 at 1000 with the DON (Director of Nursing), revealed that mortality and morbidity was not sorted or broken down per department or service. The DON revealed mortality and morbidity was only reported through physician scores. The DON revealed the emergency department service line meetings were not conducted in January and February of 2019. The interview revealed the DON was unable to locate any emergency department service line meetings minutes for 03/2019 to current. The DON revealed the manager during that time period had since left employment at the facility and the minutes could not be found. Interview revealed the DON expectation was for the policies and bylaws to be followed.

Interview on 08/16/2019 at 1015 with CMO, revealed "We [Staff] are not as diligent. We [Staff] missed it."

Based on review of policy and procedures, peer review cases, and staff interviews the facility staff failed to follow policy and procedure regarding physician peer review for 5 out of 6 physician peer referral cases reviewed. (Patients: #19, 20, 21, 22, 23) and failed to accurately gather assurance and performance data.

The findings included:
1. Review on 08/15/2019 of facility policy titled, "Ongoing Professional Performance Evaluation/ Peer Review, MS-3," approved: 03/2017, revealed " ...PEER REVIEW PROCEDURE: 1. When practitioner-specific issues are identified through organizational performance improvement monitoring, the Quality Director, or designee, will perform concurrent and/or retrospective chart review using medical staff approved criteria ... or if there is an unexpected patient outcome ...3. If the case meets the screening criteria, the case and a peer review worksheet will be sent to the appropriate initial peer reviewer for evaluation and scoring ..."

Review on 08/16/2019 of peer review cases referred for physician peer review from 03/2019 through 06/2019, revealed 5 out of 6 cases reviewed were not sent for physician peer review evaluation.

Interview on 08/16/2019 at 1420 with the Quality Director, revealed "They [5 cases for peer review] did not get forwarded for review. I forgot. It was an error."

Interview on 08/16/2019 at 1515 with the Director of Nursing, revealed "The Quality Department is responsible for ensuring any physician peer review request is followed." Interview revealed it was the expectation for policy to be followed in every case.

Interview on 08/16/2019 at 1015 with the Chief Medical Officer, revealed the Quality Department was responsible for ensuring the appropriate physician peer reviewer was assigned to every referred case.


2. Review on 08/15/2019 of facility policy titled, "2019 Performance Improvement Plan- Patient Safety & Clinical Quality," last revised 03/2019, revealed " ...To be meaningful, all data will be aggregated and analyzed and submitted to the PSCQC [ Patient Safety & Clinical Quality] for their review, consideration, and, if indicated, prioritization and actions identified. Summaries and updates will be reported to the PSCQC. The level of performance that is- what and how well processes are done to provide care/services and promote positive outcomes-will be identified through analysis ... if new processes meet expectations (process and outcome); if improvements have resulted in desired outcome; if processes maintain improvement over time ...Performance measures are selected that help determine the effectiveness of the change and whether it resulted in a sustained improvement once the change is implemented ..."

Review on 08/16/2019 of the facility`s Patient Safety & Clinical Quality minutes, revealed the core measure-median admit decision to depart for admitted emergency department patients were not being reported per policy. The review revealed no reported data for median admit decision to depart for admitted emergency department patients from 01/2019 through 07/2019. The PSCQC minutes were reviewed and confirmed by the Quality Director of no reported data for median admit decision to depart for admitted emergency department patients from 01/2019 through 07/2019.

Interview on 08/14/2019 at 1000 with the DON (Director of Nursing), revealed each department within the facility was responsible for the collection and presentation of data identified for improvement performance. The interview revealed the emergency department was responsible for gathering and presenting the data for median admit decision to depart for admitted emergency department patients. The DON revealed the Director and Managers were responsible for conducting departmental service line meetings monthly and presenting the departments data to PSCQC monthly. The interview revealed the emergency department service line meetings were not conducted in January and February of 2019. The DON revealed she was unable to locate any emergency department service line meetings minutes for 03/2019 to current. The DON revealed the manager during that time period had since left employment at the facility and the minutes could not be found.

Based on review of policy and procedures, adverse events log and staff interviews the facility staff failed to document and monitor an adverse/ occurrence event in quality assurance and performance improvement. (Patient # 21)

The findings included:

Review on 08/14/2019 of the facility policy titled, "Risk Management Plan," approved 03/2019, revealed "OBJECTIVES: ... To investigate, categorize and analyze all patient events, occurrences trends and patterns involving individuals, locations, or types of incidents and to determine appropriate action to determine appropriate action [sic] to prevent recurrence ..."

Review on 08/14/2019 of the facility policy titled, "Confidential Incident Report, ORG-138," approved 07/2019, revealed " ...Serious reportable events: Serious reportable events (SRE`s) have been identified by the National Quality Forum and have been adopted by the [named facility] ... PROCEDURES: 1. Any staff member who identifies an incident (see attached list of examples) is responsible for reporting the incident ... 6. The Quality Management Department will maintain a data base of all incidents ..."

Review of facility policy "Abuse, Neglect and Human Trafficing: High Risk Indicators of and Access to Protective Services" revised 10/2018 revealed "....Abuse- is defined as "the willful infliction of physical pain, injusry or mental anguish, unreasonable confinement....1. All (named hospital) personnel will report suspected abuse or neglect of a child, adult or elderly person to the appropriate authorities..."

Closed medical record review on 08/15/2019 of Patient #21 revealed a 14-year-old male presenting to the facility's emergency department under Involuntary Commitment on 11/17/2019 for self injurious behaviors. Review revealed the patient has a history of autism and developmental delays. Review revealed the patient remained in the emergency department waiting for bed placement until he was transferred on 01/04/2019.

Review of the facility's adverse event log on 08/15/2019 revaled no event or inicdent report was documented.

Review of the internal investgation documents on 08/16/2019, revealed on 12/14/2018 "the director of the emergency department, was in the department at the end of the ED where Patient #21 room was. She saw named paramedic, was in the patient's room and saw him lunge at the patient and pushed him down on the bed by the throat. She yelled and named paramedic loosened his grip on the patient's neck..." Review of internal documents revealed on 12/19/2019 Risk Management Director contacted their legal department who recommended they follow their abuse and neglect policy. Review of documentaion revealed Child Protective Services and Department of Social Services were notified.

Interview with the Director of Human Resources on 08/15/2019 at 1330 revealed the named paramedic was taken off the schedule on 12/14/2019 and was terminated on 01/07/2019 after investigation was complete for "inappropriate behavior toward a patient." Interview revealed the video of the event was consistant with the internal documentation.

Interview with the Director of Risk Managment on 08/15/2019 at 1345 revealed the incident was not reported to HCPR due to the recommendations from their legal department. Interiew confimed there was no filed internal incident or event report completed.

Interview on 08/15/2019 at 1045 with the DON (Director of Nursing), revealed Patient #21 was not on the list of adverse events provided. The DON confirmed the incident was not reported in the computer program.

Based on review of policies, review of medical records (Patient #7), interviews with staff, the nursing staff failed to supervise nursing care by failing to assess and reassess patient's response to pain medications in 2 of ____ medical records (#2 and #7).

The findings include:

Review of Job Description for "Paramedic" with approved date of 04/26/2017 revealed "...A paramedic's duties involve the care of all ED patients. Only nursing staff have certain assigned patients....Paramedics are assigned patient care activities as instructed/ordered by the Emergency Physician and nursing staff within their scope of practice and as alowed by facility policy....Administer medications as listed on the North Carolina Medical Board Approved Medications for Credentials EMS Personnel under the directions and supervision of a physician...."

Review of policy titled "Medication Administration Safety Policy," with revision date of 03/2019, revealed "...Monitoring Effects: 1. Medication effects on patients are routinely monitored by Nursing. 2. Therapeutic response to 'prn' (as needed) medications or a first dose of medication should be evaluated within 30-60 minutes of administration...."

1. Closed medical record review of Patient #2 revealed a 41 year old female admitted on 5/26/2019 for severe epigastric pain with diagnosis of acute pancreatitis. Review of physician medication orders dated 05/26/2019 at 2007 revealed "Morphine injection 2 mg/ml (milligrams per 1 milliliter) every 2 hours as needed for pain scale of 4-6 of 10, for pain unrelieved by oral meds or patient NPO (nothing by mouth)." Review of MAR (medication administration record) revealed documentation of administration of Morphine 2 mg IV on 05/26/2019 at 1728. Review of documentation revealed Morphine 2 mg IV was administered by EMT-P #3. Review of reassessment documentation revealed no documentation of reassessment until 2105, (3 hours and 7 minutes later). Review of MAR (medication administration record) revealed administration of Morphine 2 mg IV on 05/26/2019 at 2105 by RN #8. Review of documentation of pain reassessment revealed no documentation of pain reassessment until 2317, (2 hours 12 minutes).

Interview on 08/14/2019 at 1415 with RN #5 revealed patient should be assessed every one hour after pain medication. Interview revealed policy was not followed.

Interview with EMT-P #3 was not obtained due to unavailability.

Interview with RN #8 was not obtained due to unavailability.

Interview on 08/16/2019 at 1005 with RN #4 revealed no documentation of pain assessment on 05/26/2019 after documentation of pain medication at 1728. "The RN is responsible to reassess pain effectiveness."

2. Closed medical record review of Patient #7 revealed a 54 year old male admitted on 06/17/2019 for syncope due to anemia. Review of physician orders revealed "Percocet 5/325 mg one tablet qid (four times daily) prn (as needed) for pain." Review of MAR revealed administration of Percocet on 06/19/2019 at 0835 for pain of 6/10 by RN #6. Review of reassessment revealed documenation on 06/19/2019 at 1200, (3 hrs and 25 minutes).

Interview with RN #6 was not obtained due to unavailability.

Interview on 08/15/2019 at 0835 with DON revealed nurses should reassess patient's response to pain medications within the hour. Interview revealed policy was not followed.

Based on review of policies, observations, review of nurses check lists, and interviews with staff and the facility's Infection Control officer failed to ensure the control of infections followed procedure for cleansing IV (intravenous) port prior to administering medications in 1 of 1 observed patients receiving IV medications. (#6).

The findings include:

Review of the procedure titled "Scrub the Hub!" (no date) revealed "...SCRUB THE HUB YOU ARE ACCESSING EVERY TIME YOU ACCESS IT!...To scrub the Hub: 1. Perform hand hygiene. 2. Don clean or sterile gloves. 3. Use a scrubbing device with an alcohol product such as chlorhexidine with alcohol or 70% alcohol to disinfect catheter hub...If you are using a pad, make sure you don't ontaminate it before use and use only on one hub. Prep pads should NEVER be reused. 4. Rub for 10 to 15 seconds...generating friction by scrubbing in a twisting motion as if you were juicing an orange. Make sure you scrub the top of the hub well, not just the sides. 5. Allow the hub to dry. Prevent it from touching anything while dryig. 6. Access the stopcock or injection port only with sterile devices. 7. Infuse medication..."

Observation on 08/14/2019 at 0900 of RN #10 administering IV medication to Patient #6. Observation of RN #10 connecting Saline syringe to hub of peripheral IV. Observaton continued with RN #10 disconnecting the saline syringe then connecting IV medication to hub. Observation did not reveal scrubbing of the hub during the process.

Review of medical record of Patient #6 revealed a 77 year old female admitted on 08/10/2019 for decreased alertness and mentation. Review of medication administration record dated 08/14/2019 at 0937 of "MethylPrednisolone 40 mg/ml: intravenous once a day (0.75 mg x 40 mg/ml per dose) revealed admin (administered) by RN #10 on 08/14/2019 at 0937.

Interview on 08/10/2019 at 0955 with RN #10 regarding the procedure of scrubbing the hub before attaching the syringes to an IV line. Interview revealed she did not scrub the hub during the IV medication adminstration. Interview revealed the hubs should be scrubbed with alcohol before each syrine is attached.

Interview on 08/14/2019 at 1020 with Infection Control Nurse revealed scrubbing of the hub is an essential part of the Infection Control process. Interview revealed nurses that do not scrub the hub are not performing "best practice." Interview revealed the scrubbing of the hub should been done with every IV medication administration.

NC00152147, NC00153633, NC00153672