HospitalInspections.org

Based on a review of documents and staff interviews it was revealed the facility failed to follow their own policy for identification and reporting of abuse. This failure has the potential to adversely affect all patients.

Findings include:

1. A review of document titled "Identification/Reporting of Abuse, revision date 06/17, stated in part: "D. Reported or Suspected Abuse or Neglect by an Employee: (5) The staff allegedly involved in the abuse will be removed from the schedule until such time as any investigation has been completed."

2. An interview was conducted with the Director of Quality and Program Improvements on 10/6/20 at 3:16 p.m. When asked if the employee was removed from the schedule after the allegations she said, "No." The employee was moved to another unit. When asked if the employee was removed after the search warrant from the police department was received on 9/28/20 she stated, "No." She stated the Chief Executive Officer (CEO) made the decision to allow the employee to be moved to another unit. She stated they did an investigation on 9/18/20 after the allegation on 9/17/20 and found it to be unsubstantiated. No other investigation was conducted into the allegations from the police.

3. During a telephone exit conference on 10/7/20 at 8:30 a.m. the CEO stated the facility felt the allegation from the police was the same as the allegation investigated by the facility on 9/18/20. He concurred no additional investigation was completed.

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A. Based on medical record reviews and staff interviews it was revealed the nursing staff failed to follow hospital procedures for nursing assessments when a patient arrives at the facility. This failure was identified in three (3) of twelve (12) medical records reviewed (patient #2, 11 and 12). This failure has the potential to adversely affect all patients.

Findings include:

1. During entrance conference on 10/6/20 at 8:07 a.m. the Chief Executive Officer and the Chief Nursing Officer stated the computer system for the whole corporation has been hacked and held for ransom as of 9/27/20 at 1:00 a.m. This ransom affects two hundred and fifty (250) different facilities. All documentation is on paper as of 9/27/20. There is no computer access to any medical records before 9/27/20.

2. A review of the medical record for patient #2 revealed patient #2 was admitted on 10/1/20. A nursing assessment note form dated 10/1/20 at 8:00 a.m. was not completed, signed, dated and timed. No admission data base form was noted in the chart.

3. A review of the medical record for patient #11 revealed patient #11 was admitted on 9/30/20. A nursing admission data base form dated 9/30/20 at 8:00 p.m. was not completed, signed, dated and timed.

4. A review of the medical record for patient #12 revealed patient #12 was admitted 9/28/20. A new admission nursing note was noted for 9/28/20 at 11:30 p.m. The nursing admission note did not include a nursing assessment. A nursing assessment note form dated 9/29/20 at 7:00 p.m. was not completed, dated or timed. No admission data base form was noted in the chart.

5. An interview was conducted with the Director of Quality on 10/6/20 at 3:16 p.m. When asked about the procedure for nursing assessments after a patient arrives to the unit, she stated the nurses are expected to complete a nursing assessment within twenty-four (24) hours after arriving to the unit. She concurred all documentation must be signed, dated and timed.


B. Based on a review of the observation sheets for patient #1 it was revealed the staff failed to accurately complete the patient observation record for patient #1. This failure was identified in one (1) of twelve (12) medical records reviewed (patient #1). This failure has the potential to adversely affect all patients.

Findings include:

1. An interview was conducted with the Registered Nurse (RN) on 10/5/20 at 9:05 a.m. He stated prior to going to the cafeteria on 9/13/20 patient #1 acted like she was having a seizure. She said she felt something coming on. He told her to lay down. After about half an hour she was told everyone was going to lunch and she got up and said she is ready to go to lunch. He stated he walked beside her to the cafeteria and even got her a tray. The doctor verified it was ok for her to go to lunch. He stated while in the cafeteria patient #1 acted like she was having a seizure. He stated he and a Mental Health Technician (MHT) escorted the patient back to the unit.

2. A review of the video for 9/13/20 revealed the RN and the MHT were escorting the patient back to the unit. At 12:00:54 p.m. they were located at the unit door. Patient #1 was staggering when held by the RN and MHT at the unit door.

3. A review of the observation sheet for patient #1 on 9/13/20 revealed patient #1 was documented as calm and in the dayroom from 10:30 a.m. to 11:45 a.m. and at 12:00 p.m. documented as a seizure and in the hallway.

4. An interview was conducted with the Director of Quality on 10/6/20 at 4:46 p.m. She stated she reviewed the video for 9/13/20 and patient #1 went to her room at 11:22 a.m. and then went to the cafeteria at 11:40 a.m. She concurred the staff failed to accurately complete the observation sheets for patient #1.

5. During a telephone exit conference on 10/7/20 at 8:30 a.m. the CEO stated the staff did not accurately complete the monitoring sheets or complete a nursing assessment as per hospital procedures.