HospitalInspections.org

Based upon interview and record review the facility failed to protect the rights of 1 of 1 patients (Patient #1) to be free from abuse in a sample of 10 reviews and failed to take steps to protect all patients in the Emergency Department (ED) after an allegation of potential abuse/mistreatment of a patient by Nurse A was reported.

Findings include:

The facility failed to identify a reported event as potential abuse/Caregiver Misconduct per facility policy. See tag A0145.

The facility failed to protect Patient #1 and other patients in the ED while an investigation was conducted. See tag A0145.

The facility staff failed to report the alleged incident of abuse/Caregiver Misconduct in a timely manner. See A0145.

The facility failed to thoroughly investigate and provide documentation of the investigation per facility policy. See tag A0145.

Based on record review and interview, the facility staff failed to: identify a reported event as potential abuse per facility policy; report the alleged incident of Caregiver Misconduct in a timely manner to the Nursing Supervisor and to Corporate Counsel within 24 hours of learning of the event per facility policy; thoroughly investigate and document an investigation of the allegation of abuse per facility policy; and take steps to protect patients from further harm in 1 of 1 Patient events reviewed (Patient #1) in a sample of 2 safety events submitted by employees.

Findings Include:

A review of the facility policy, titled "Caregiver Misconduct Investigation and Reporting", last updated 08/13/2018, revealed: "...I. PURPOSE To establish a process for receiving, investigating, and, if required, reporting allegations of Caregiver Misconduct and injuries of unknown source as required by the Wisconsin Caregiver Law...III. DEFINITIONS ...5. Examples of Abuse may include, but are not limited to: a. Hitting, slapping, pinching, kicking ...IV. PROCEDURE ...B. Source of Allegations of Caregiver Misconduct. [Facility Name] staff may become aware of potential cases of Caregiver Misconduct or an injury of unknown source by one or more of the following: ...4. Patient Safety Net Report (hero event reporting) ...C. Initial Actions when Learning of Alleged Incidents of Caregiver Misconduct. Whenever any [Facility Name] staff member becomes aware of an alleged incident that may meet the definition of Caregiver Misconduct, they are required to do the following: 1. Report allegations of Caregiver Misconduct to supervisor a. Alleged incidents of Abuse and/or Neglect. i. All staff are required to immediately report any suspected incidents of Abuse and/or Neglect to their supervisor or their supervisor's designee. If the incident occurs after hours or on the weekend/holiday, the nursing supervisor shall be notified. ii. The supervisor or designee is required to report the incident to their Director and to the Corporate Counsel (608-261-0025) within 24 hours of learning of the alleged incident to ensure that the incident is documented and an investigation is appropriately conducted...2. Take measures to protect the patient from further harm. As soon as possible upon learning of the alleged incident of Caregiver Misconduct, steps must be taken to protect the patient from possible subsequent incidents of misconduct or injury. Responsive measures may include, but are not limited to, removing the alleged caregiver from providing the patient's care, moving the patient to another clinical area, addressing and treating evidence of physical or emotional harm, and removing the suspected caregiver from practice. D. Investigating and Documenting Alleged Incidents of Abuse and Neglect. 1. Time Frame for Completing and Reporting Investigation to Corporate Counsel. To the extent Corporate Counsel requests [Facility Name] staff assistance with an investigation involving alleged incidents of Caregiver Misconduct, the [Facility Name] staff member is expected to complete and provide documentation of his or her investigation to the Corporate Counsel within 3 days ..."

Review of Patient #1's medical record review reveled, Patient #1 was a 21-year-old male that arrived to the facility's Emergency Department (ED) on 04/02/2022 at 2:28 AM via EMS (Emergency Medical Service) transport and was discharged to home on 04/02/2022 at 6:28 AM; Registered Nurse (RN) A was assigned to care for Patient #1 during this ED admission and was the discharging Nurse. ED note created on 04/02/2022 at 6:37 AM by Nurse A revealed, "Pt [patient] on cell phone during discharge instructions, Pt verbalizes understanding, getting dressed, and waiting for ride in the ED waiting room."

Review of the facility Adverse Safety event log revealed:

On 04/02/2022 at 4:06 AM there was a Safety event entry by Security Guard Q describing the event of 04/02/2022 and the allegation of "Staff Aggression" by Nurse A that revealed, Security Guard Q was called to the ED (along with Security Guard R) for unknown patient safety concerns regarding Patient #1 at approximately 3:08 AM. Security Guard Q documented, "At no point was the patient aggressive or uncompliant with requests and was easily redirected. When RN [A] returned to the room however, the patient tried again using [his/her] right arm and right hand to feel [his/her] left arm with the IV, when the nurse [A] stopped [him/her] and aggressively pushed [his/her] right arm back across [himself/herself] and to the other side of the bed while telling him not to touch that [IV]. This aggression at this point seemed very inappropriate to me ...Nurse [A] then decided to wrap the patient's left arm/IV but again, was aggressive with wrapping and made me uncomfortable watching her [Nurse A] provide the type of care that [he/she] was. When [he/she] was done, [he/she] pushed/let the arm plop back down onto the bed which I felt to be very inappropriate and once again made me uncomfortable. After [he/she] did that the patient lifted [his/her] head off of [his/her] pillow to look at [him/her] and at the IV, but [he/she] forcefully pushed [his/her] head back down onto [his/her] pillow while telling [him/her] to relax... Nurse [A] seemed to be doing things quickly in an aggressive manner ...and because of that, during the transfer [he/she] almost hit the Patient's [Patient #1] head against the CT machine which was noticed by all Staff that were present...those staff members were identified as X-Ray Tech [S] and CT Tech [X] both with the Radiology team ..."

On 04/02/2022 at 5:20 AM there was a Safety event entry by Security Guard R describing the event of 04/02/2022 and the allegation of "Care Coordination" by Nurse A that revealed, "Security was asked to assist with a Patient. Patient was none [sic] aggressive but RN RN [sic] Nurse [A] was very unprofessional and aggressive with patient at times. Such as pushing patient head, grabbing and tossing patients arm and also aggressively moving patient over to CT and possibly hitting patients head on the CT. Patient was never aggressive but mostly confused and unsteady on feet."

During an interview on 05/25/2022 at 11:18 AM with X-ray Tech S, when asked how he/she was involved in an event that was reported in the hero event reporting system on 04/02/2022 involving CT staff, a ED Nurse and Security Guards, Tech S stated, "CT Tech [X] was working alone that night, I went in to help; [Nurse A] seemed rushed and quick movements with the Patient [Patient #1], I was surprised by this because the patient was having a head CT. Then [Nurse A] walked past me and said 'I didn't have fucking time for this' and left the room ..."

During an interview on 05/25/2022 at 12:00 PM, Accreditation & Regulatory Specialist E stated, "We followed the hero/safety event policy, we didn't go on the route of Caregiver Misconduct because we felt it didn't constitute-and no triggers at the time." When asked if CT Tech X was available for interview, Specialist E stated that CT Tech X is currently out of the facility on vacation.

During an interview on 05/25/2022 at 12:05 PM, Accreditation & Regulatory Specialist D stated, "We were thinking we should be following the hero (safety event reporting) policy, not the Caregiver Misconduct; it didn't meet the definition of abuse according to our policy."

During an interview on 05/25/2022 at 3:34 PM with ED RN Lead T, when asked what was reported to him/her from the Security Officer/s on the night of the incident involving Nurse A, Lead T stated, "The Security Officer said that both of them [Security and Radiology] were concerned that the patient was being treated poorly. The picture I got from Security was that Nurse [A] was flinging the patient around, turning throwing his arm around." When asked if he/she was the one who initially called Security in regards to Patient #1 in the ED, Lead T stated, "I believe I did call Security, the Patient [#1] was not aggressive, just not keeping things on and taking things off." When asked if he/she witnessed Nurse A being aggressive towards Patient #1 on the night shift of 04/02/2022, Lead T stated, I did witness Nurse [A] pick up the Patient's [Patient #1] right arm and just let it drop on the side rail-I think she was testing to see if [he/she] was asleep."

During an interview on 05/24/2022 at 3:42 PM with Medical Imaging Manager N, when asked what is expected of staff if they witness aggression and/or abusive behavior towards patients, Manager N stated "The hope would be they come to me or enter into the hero event reporting system, we encourage our staff to enter all incident details into the hero reporting system." When asked if he/she recalled an incident that was entered into the hero reporting system regarding Medical Imaging staff, Security Guards and a ED Nurse, Manager N stated, "I do recall this incident, the ED Nurse [A] was handling a patient very rough and staff was concerned." When asked what his/her part was in the incident follow-up, Manager N stated, "I made sure ED Manager [H] was aware of the event, we discuss these types of events in huddles only Monday through Friday."

A review of the Emergency Department staffing schedule from the time of the event reported to ED RN Lead T on 05/25/2022 at 3:34 PM revealed, Nurse A worked the night shift (7:00 PM-7:30 AM) on 04/01/2022, the night shift (7:00 PM- 7:30 AM) on 04/02/2022 and the night shift (7:00 PM- 7:30 AM) on 04/03/2022. The incident was not addressed with Nurse A at the time of the allegation and Nurse A worked two more shifts (over the weekend). The allegation was not reviewed for investigation until Monday, 4/4/2022.

During an interview on 05/24/2022 at 4:14 PM with ED Manager H (Nurse A's Supervisor), when asked about follow-up he/she was involved in regarding the event reported on 04/02/2022 involving ED Nurse A, Manager H stated "Concerns were escalated and came to my attention, it involved a young confused patient and colleagues thought they saw actions that were aggressive and not warranted. I did a deep dive into the patient's [Patient #1] chart and questioned those involved, the event took place on a Friday overnight shift and I learned of the event Monday morning through an automated email from the hero event reporting system; Nurse [A] worked until 7:30 AM on that Monday morning, then he/she [Nurse A] was on vacation for 2 weeks. I partnered with HR [Human Resources] to construct a series of questions to ask the Nurse [Nurse A] when [he/she] returned from vacation, you will see those questions in [his/her] HR file. I had a scripted and prepared conversation with a transcriptionist taking notes. He/she [Nurse A] did not recall anything about that night or the Patient [Patient #1]." Manager H stated that she counseled Nurse A (along with HR involvement) and told Nurse A that "future complaints could result in Caregiver Misconduct."

During an interview on 05/25/2022 at 6:42 AM with Security Guard Q in regards to the event he/she placed on 04/02/2022 regarding Nurse A, when asked if Security Guard Q reported the incident to the Nursing Supervisor during the shift the event happened, Security Guard Q stated, "I spoke with the ED Charge Nurse [T] on duty that night out of a safety concern standpoint, I felt compelled to make [him/her] aware of the Nurse's [A] behavior; Charge Nurse [T] shared with me that this wasn't a first time occurrence of this nature with this Nurse and encouraged me to write a report to address things; I also did report the incident to my Supervisor [Z], and I talked to both Techs that were in the room and asked them if it was ok to put their names on the report." When asked if he/she was contacted after the event as part of the investigation, Security Guard Q stated, "No, I just got a confirmation email that my hero (computer-generated reporting system) report was received."

During an interview on 05/25/2022 at 11:50 AM with ED Manager H (Nurse A's Supervisor), when asked what steps he/she took after being notified of the event on day #3 (04/25/22) following the event involving Nurse A, Manager H stated "I needed to involve HR [Human Resources] and asked for help from remote HR person [Y], we drafted questions to ask [Nurse A] and emailed those (along with the hero event information) to HR person [Y] and ED Director [I]." When asked who the Administrator would have been during the time the event happened, ED Manager H stated, it would be the ED Nursing Administration on-call; which would have been ED Director [I] that night." When asked if the on-call Administrator was contacted, Manager H stated, "No, ED RN Lead [T] did not escalate it up."

During an interview on 05/25/2022 at 10:56 AM with ED Director I, when asked about his/her involvement regarding the event reported in the hero event reporting system involving ED Nurse A on 04/02/2022, ED Director A stated, "My involvement was more of a FYI [For Your Information] from ED Manager [H] to me, as this employee [Nurse A] was applying for a higher position and ED Manager [H] wanted to loop me in." When asked if this reported event was under investigation for possible Caregiver Misconduct, Director H stated, "I felt like the information we had was not Caregiver Misconduct, we needed to learn more; [ED Manager H] was working with Employee Relations." When asked if he/she was contacted within 24 hours of the incident, ED Director I stated, "No, because did this really qualify as abuse? What I was made aware of was quick and aggressive movements by the Nurse [A]." When asked if Corporate Counsel was contacted, ED Director I stated, "Can't answer that, we were not following up on Caregiver Misconduct, Employee Relations guides us."

During an interview on 05/25/2022 at 4:28 PM with Employee Relations Specialist U, when asked if he/she contacted the two Security Guards regarding the follow-up investigation in response to the hero events they submitted involving Nurse A on 04/02/2022, Specialist U stated that Security Guards had nothing more to add to what they submitted in the hero event reporting system. When asked if this is typical process, Specialist U stated, "Every time a case is assigned in the system I see if they would like a Employee Relations consultant from HR (Human Resources) to reach out them; if they say 'no' then we don't do anything-the Director then takes over." When asked if the he/she reached out to the other 3 employees listed on the hero event reporting system that were listed on the event report as 'people involved in the event who may have additional information', Specialist U stated, "No, I did not reach out to the additional people listed."

A review of Nurse A's personnel file revealed, Drafted Interviewing Questions discussed with Nurse A on 04/22/2022 at 3:00 PM (20 days after the reported event) by ED Nurse Manager H (and transcribed answers by HR Representative J) and Nurse A's Counseling Template discussed with Nurse A by ED Nurse Manager H on 05/04/2022 (32 days after the reported event).

The facility did not follow their policy for "Caregiver Misconduct and Reporting" when an alleged incident of Caregiver Misconduct was reported both in person to ED Charge Nurse T and via the Hero Event Reporting System. The incident was not reported immediately to the Nursing Supervisor, Director and Corporate Counsel as directed by the facility policy. ED RN Lead T failed to report the incident to the Corporate Counsel 24 hours of the event, and failed to escalate the event to the administrator on-call "no later than 24 hours after discovery of the event or during the shift when the event was discovered"-per facility policies. The facility failed to take measures to protect Patient #1 and all ED Patients as soon as possible upon learning of the alleged Caregiver Misconduct event. The facility also failed to conduct a thorough investigation; there were no documented interviews conducted with Patient #1 or with staff named (CT Tech X, X-Ray Tech S and ED RN Lead T) in the hero event reporting system who may have had additional information regarding the event to help determine what, if anything, happened and to determine the complete factual circumstances surrounding the alleged incident.