HospitalInspections.org

Based on interview and document review, it was determined that the hospital failed to ensure that all patients received care in a safe setting. The hospital's failure to do so resulted in harm to one patient, and placed all patients who were transferred from gurneys and/or received care on a procedure table, at risk for harm.

Findings include:


Patient Fall in Radiology

On July 15, 2010, the Chief Nursing Officer (CNO), the Director of Quality Improvement) and the Director of Radiology were interviewed about the allegations contained the the complaint, specifically that a patient had fallen from a gurney in the radiology department. Discussion was held regarding the hospital's awareness of the events and response to same.

The allegation was that Patient #1 had "...been dropped in the x-ray room on the floor..." and that the event had not been documented "...in the logs...".

A review of internal hospital documents revealed that the patient had fallen from a procedure table in the radiology suite on 4/12/2010. On 7/15/2010, the Director of Radiology that the procedure table the patient had been on had not had safety straps to help prevent patients from falling or rolling off of the table. The Director stated that s/he had discussed the use of straps with the Biomedical Engineer, who stated that no safety straps could be used on the procedure table due to the design of that table.

The Director stated that there were no safety straps on the procedure table as of the date of the investigation, 7/15/2010. When questioned as to how patients would be kept from rolling or falling off of the procedure table in the future, the Director stated that the plan was for radiology staff to be in close proximity to the patients. The Director acknowledged that staff would have to stay behind the protective wall during radiology procedures, and likely would be unable to prevent a fall even if they saw the patient begin to fall or roll off of the table.

The CNO and the DQI were questioned as to what assessment had been done hospital-wide to assure that patients were safe in other areas where patients might be transferred to procedure tables. The CNO was asked if there were safety straps on procedure tables in the Operating Rooms or in the Emergency Department. The CNO stated that s/he was not sure, but would immediately assess those areas for potential risk relating to safety straps on procedure tables.

The DQI was also asked to provide that portion of the medical record for Patient #1 which documented the post-fall assessment for injury. The DQI stated that there was no such documentation in the patient's medical record.

The hospital's policy and procedure "Fall Prevention Policy" was reviewed and found to contain the following directives:

"IX. Documentation and Follow up
Following a post-fall assessment and any immediate measure to protect the patient:

2. Progress note should be entered into the patient's record including the results of the post-fall assessment, and offer notification of patient's family..."

The hospital's failure to document the post-fall assessment of Patient #1, and to investigate the reason for the fall of Patient #1 to the floor in the Radiology Department, as well as the failure to expand the risk evaluation from the Radiology Department to other areas of the hospital, placed all patients who were transferred to procedure tables at risk of injury.


Abuse and Neglect Reporting

The hospital's policy and procedure "Patient Abuse" was reviewed and found to contain incorrect and incomplete information regarding the identification and reporting of suspected abuse/neglect/exploitation.

The following points were discussed with the Chief Nursing Officer (CNO) and the Director of Quality Improvement (DQI):

1.) The definition of "exploitation" included only the "illegal and improper use of a person or that person's resources for another person's profit or advantage. Requiring a person to be involved in criminal activity or imposing unreasonable work standards". The definition did not include activities such as taking unauthorized pictures of patients or sexually exploiting patients.

2.) The definition of "vulnerable adult" had not been updated to include the Washington Administrative Code definition, which includes all "...hospitalized adults".

3.) On page 3 of 5, the policy stated that "all licensed health care professionals are required by law to report a suspected incident of non-accidental injury, neglect, sexual abuse or cruelty to a child elderly or other vulnerable adult who appears to be legally responsible for that individual's welfare, including members of the health care team." The definition did not include abuse, etc. by others such as a spouse, child, significant other, spiritual leader who may not have been legally responsible for the individual's welfare.

4.) On page 3 of 5, the policy also stated that "the abuser may be a souse, another child, a family member, legal guardian or a primary caregiver. The abuser may also be a direct or indirect member of the healthcare team." Reference item #3.

5.) On page 4 of 5, the policy directed staff to "make referral to appropriate agency within one Administrative day. Children's Protective Services, Adult Protective Services and Law enforcement if indicated".

Discussion was held with the CNO and the DQI regarding the scope of authority and services of Children's Protective Services and Adult Protective Services, both of which are divisions of the Department of Social and Health Services. Further discussion was held regarding the scope of authority and services of the Department of Health (DOH) and when referrals should be made to DOH. Discussion was also held about the need to identify when referrals to law enforcement were "indicated".

The policy did not include what steps, if any, were to be taken if the alleged perpetrator was a hospital employee, staff, contractor, volunteer or clergy. No additional policy was provided to address those possibilities.

The hospital's failure to develop and implement a complete and accurate policy and procedure regarding the identification and reporting of potential abuse/neglect/exploitation of patients resulted in employees not having complete and accurate information and guidance in the event of a potential abuse/neglect/exploitation situation. The lack of complete and accurate information on the subject placed all potential victims of abuse/neglect/exploitation at risk for unidentified and unreported events.