HospitalInspections.org

Based upon policy review, open and closed medical record review, and staff interviews, the facility staff failed to follow facility policy regarding reporting alleged patient / patient abuse for 1 of 1 patients (patient #3).
Review of the facility's policy # ADM 1009 Patient Abuse, Neglect, or Misappropriation: Identifying and Reporting states "...DEFINITIONS: ...Procedure: ...D. Reporting: ...3. Any facility staff member who received information regarding or witnesses an incident of patient abuse ...must report such verbally and in writing. The report should be made immediately to either the Patient Representative or Risk Manager..."


Closed medical record review for named patient (#3) revealed an 8 year old female admitted involuntarily on 05/01/15 with the diagnosis Disruptive Mood Dysregulation Disorder and Attention Deficit Hyperactivity Disorder. Review of a Nursing Assessment/Reassessment dated 05/03/15 at 1520 stated "during family visit patient reported she was being hit by roommate. Parents upset, requested AMA (against medical advice). Filled out paperwork. Requested room change, peer moved out of patient room. Patient states she feels safe at this time."
Review of the Incident Report log for 05/03/15 failed to reveal an incident report for this alleged patient/patient abuse.
An interview with RN (Registered Nurse) #1 on 10/14/15 at 1200 revealed "...I do remember that day. Patient #3 told her family she was being hit by her roommate during a family visit on a Sunday afternoon. She had not reported this to staff, there were no witnesses, the roommate denied hitting her, and I did not really believe that it had happened. I thought she was saying it so her parents would take her home. That's why I did not complete an incident report. I did move the accused peer to another room and patient #3 said that she felt safe. I did not report the incident to anyone..."
An interview with RN # 2 on 10/13/15 at 1015 revealed "we do not always complete incident reports every time a patient reports alleges abuse. If there is a witness or if there is injury, we always complete an incident report. We did not know of the alleged incident until we received the complaint from the MCO. If an incident report had been completed, it would have gone to myself, Risk Management, and others, and we would have investigated it then."
An interview with RN #4 on 10/14/15 at 1100 revealed "...it is not unusual to not have an incident report if there were no witnesses and no injury..."
An interview was conducted with Employee #3 on 10/14/15 at 1330 and confirmed the policy was not followed.

NC00110335