HospitalInspections.org

Based on interview and document review, the facility failed to implement a policy that protected patients including patient #1 from an alleged abuser while an investigation was in progress, resulting in the potential for unsatisfactory outcomes for any of the 683 patients currently being served by the facility. Findings include:

(See A-145)

Based on interview and document review, the facility failed to implement a policy that protected 1 (#1) of 2 patients reviewed for abuse, from an alleged abuser while an investigation was in progress, resulting in the potential for unsatisfactory outcomes for any of the 683 patients being served by the facility. Findings include:

On 2/8/2022 at 1150, a review of the medical record for patient #1 revealed the following:
Patient #1 was a 71-year-old male who was admitted to the facility on 2/8/2021 and discharged on 2/15/2021. The patient was described as awake, alert and oriented according to the History and Physical (H&P). The patient presented with a diagnosis of parotid carcinoma and was scheduled for surgical procedures.

On 2/8/2022 at 1330, an interview and review of a Complaint/Grievance investigation was conducted with the Manager of Care Experience (Staff F) pertaining to the patient #1. According to Staff F, their department was contacted on 2/18/2021 by their legal department with the message that the patient's wife wanted to file a complaint regarding the service that the patient had received when he (#1) was hospitalized at their facility. Review of the grievance revealed the complainant identified that the incident happened on 2/10/2021 and named a nurse who had taken care of the patient and alleged the nurse "head butted and threw pillows" at the patient.

Staff F said a RL (electronic Risk report), was entered for follow-up and review of the allegations. Staff F said the grievance was investigated by the Leadership team and Nurse Manager (Staff H). According to Staff F the complainant was notified by mail that their investigation had been completed as of March 15, 2021. Staff F said they determined their care of the patient had been appropriate and therefore the grievances were not substantiated.

On 2/9/2022 at 1440, Staff H was interviewed, and she was asked if the nurse (Staff AA) was removed from the schedule or suspended during the investigation. At that time, she replied no she (Staff AA) had not been.

Staff A was interviewed on 2/9/2022 at 1510, regarding the grievance submitted on behalf of the patient (#1) and the facility's policy for investigating allegations of staff to patient abuse allegations.
On 2/9/2022 at 1515, after reviewing the facility's policy she (Staff A) said, maybe we should have suspended her which is our policy.

Review of the facility's "Tier 1: Disruptive Behaviors" policy with an effective date of 1/1/2022 and revisions dates noted on 12/1/20218 and 2/9/2022, documented the following:
Policy
(Name of Health Care System) has zero tolerance for intimidating or disruptive behaviors in the workplace and is committed to culture of safety, which supports effective communication amongst team members. Zero tolerance requires that all allegations are investigated, and appropriate actions are taken, which may include coaching and/or corrective action up to and including termination of employment, based on the seriousness of the event ...
Procedures
Reporting an event
" ...when an allegation of a standard conduct, policy or procedure violation has been reported to a manager/supervisor, the manager/supervisor shall immediately conduct an investigation to determine the validity of the allegation and shall respond back to the involved parties once the investigation has been completed ...If the employees behavior is disruptive to normal business operations in any way or hazardous to patients, visitors, or other, the supervisor should: ...Suspend the employee pending the investigation outcome."
However, that was not done.

Based on interview and record review, the facility failed to develop and implement policy/procedure for additional precautions for all non-immunized COVID-19 health care exempt staff that included 2 out of 5 Staff (X and Y), that were not fully vaccinated for COVID-19 infection, resulting in the potential for the transmission and spread of COVID-19 infections for all 683 patients being served by the facility. Findings include:

On 2/8/2022 at 1030 during an interview the President (Staff A) and Chief Nurse Officer (Staff B) were queried regarding their policy/procedure for Health Care Staff Vaccination for COVID-19 immunization. On 2/8/2022 at 1035 Staff A replied, "It's mandatory for all staff unless they have medical or religious exemptions."

On 2/9/2022 at 1330 a review of employee exemptions records for Staff X and Y revealed the following:

Staff X was a Nurse Assistant, currently employed. There was no evidence that she (Staff X), had requested and/or was granted a Medical or a Religious Exemption following a reaction to the first dose of the Pfizer vaccine dated 9/20/2021.

Staff Y was a Registered Nurse, currently employed. She was granted a Temporary request for Medical Exemption on 8/16/2021. It was noted that it would be okay for her to receive the vaccine post pregnancy with an estimated delivery date of 10/31/2021. However, there was no further evidence that documented that she (Staff Y), had requested and/or was granted a Medical or a Religious Exemption following her return to work.

Staff C was queried on 2/9/2022 at 1445, regarding additional precautions for non-vaccinated staff with medical or religious exemptions. Staff C was asked if weekly testing for COVID-19 was done or if those unvaccinated staff were required to a wear a N-95 mask. On 2/9/2022 at that time, Staff C replied, no we don't do weekly testing, she said we only require the N-95 for staff who are providing care for patients with COVID or during Aerosol Generating Procedures (AGP's).

Staff A was queried on 2/9/2022 at 1510, regarding their policy for additional precautions for unvaccinated staff with medical or religious exemptions to mitigate the risk of transmission of COVID-19 such as weekly testing for COVID-19 and wearing an N-95. At that time, Staff A replied, no N-95's and weekly testing for unvaccinated is not required. Staff A said, all staff have to use the App for COVID screening prior to reporting for work. She said if they don't pass the screening, they must call Employee Health for follow-up.

Review of the facility's "Tier 1: Mandatory Vaccines" policy with an effective date of 12/1/2021 documented the following:

Exemptions
(Name of organization) recognizes reasons for not receiving mandatory vaccinations.
Bona-fide Medical Reason
A. Must be documented by (Name of organization Personnel's health care provider).
B. (Name of organization Affiliated Personnel) must submit the completed appropriate Medical Exemption Request for each vaccine for which a medical exemption is being requested.
C. Temporary medical exemptions are only valid for the period identified on the exemption form.
D. (Name of organization Affiliated Personnel) are advised to contact their health care provider regarding any medical concerns related to mandatory vaccines.
Bona-fide Religious or Spiritual Reason
A. (Name of organization) respects the right of all (Name of organization-Affiliated Personnel) to practice and express his or her own religious and spiritual beliefs. (Name of organization Affiliated Personnel) ...must provide documentation of this to Employee Health or Hospital Administration from his or her religious leader for determination of exemption.
B. (Name of organization Affiliated Personnel) who do not belong to a formal religion, or who have sincerely held spiritual belief whim differs from the religion to which they belong, may submit an exemption form without a signature from a religious leader, however, they might be asked a series of standard questions regarding the nature of their belief.

Further review of the facility's policy revealed there were no additional precautions for staff who were granted exemptions from vaccination to mitigate the risk of the transmission of COVID-19 infections.