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The hospital failed to meet the patient's right to receive a written notice of its decision in a grievance investigation by failing to notify the patient's guardian of the results of an abuse allegation for 1 of 2 allegations for Pt # 2.

The findings include:

Review of a Policy Number 2-7, "Grievance, Patients' Right To", effective 07/22/2011, revealed "...Patient complaints that become grievances also include situations where a patient or a patient's representative telephones the hospital with a complaint regarding their patient care or with an allegation of abuse or neglect....All verbal or written complaints regarding abuse, neglect, patient harm or hospital compliance with CMS requirements, are to be considered a grievance for the purposes of these requirements....The patient advocate conducts an inquiry and provides a response in writing to the patient/ patient representative within seven (7) days of receipt of the grievance. ..."
Closed medical record review of Pt # 2 revealed the patient, a 13 year old, was admitted on 06/08/2014. Review of the Psychiatric Assessment, revised 06/09/2014 at 1321, revealed diagnostic impressions of "...Mood disorder (psychological disorder characterized by disturbance of the mood, such as depression or bipolar disorder)....Conduct disorder (disorder involving a pattern of disruptive or violent behavior or trouble following rules)....Attention-deficit hyperactivity disorder (ADHD - involving attention difficulty, impulsiveness). ..."
Review of a Hospital Document, dated 07/02/2014, revealed the advocate received a message from Pt # 2's guardian/mother and returned the call. Document review revealed the guardian/mother stated the patient told her a staff member "...grabbed his arm and pushed him down the hall during a conflict pt was having with a peer. ..." Further review revealed the Advocate and a Supervisor met with Pt # 2 to gather information and the patient reported a Certified Nursing Assistant (CNA) "...grabbed pt's arm when pt was 'rough housing' with a peer. (Pt # 2) demonstrated ( CNA last name) redirecting pt away from the conflict. (Pt # 2) did not report or demonstrate anything abusive. ..."
Interview with Advocate # 13 on 03/19/2015 at 1625 revealed Pt # 2 reported to him that he was grabbed and pushed down the hall and the Advocate asked him to demonstrate what happened. When Pt # 2 did so, interview revealed he showed that the CNA put his hand on him and guided him down the hall, but not in a forceful way. Interview revealed "...What was demonstrated was not abuse or a restrictive intervention." Once Advocate # 13 realized it was not abuse, nothing further was done. Interview revealed Advocate # 13 did not follow-up with the patient's guardian. Interview revealed if there had been a formal investigation, he would have followed-up with the guardian regardless of the results of the investigation.
Interview on 03/20/2015 at 1130 with Director # 14 revealed she had a later conversation with Pt # 2's guardian/mother, but no mention of this issue came up. Interview revealed the mother's report was viewed as an allegation of abuse that did not rise to a full investigation. It was not viewed as a complaint or grievance. Interview revealed "...I agree that the mother should have gotten feedback on the result of the investigation. ..." Interview confirmed the grievance policy was not followed.

Based on hospital policy review, medical record reviews, incident log review and staff interviews, the hospital staff failed to report an allegation of staff to patient abuse for 2 of 4 sampled patients that alleged staff to patient abuse (#3 and #2).

The findings include:

Review of the hospital's "Abuse, Neglect, Exploitation and Other Rights Infringements" policy effective January 31, 2014 revealed "...It is the policy of (named hospital) that all patients have the right to be free from abuse, neglect, and exploitation, and rights infringement, including falsification of records. ... The investigation process will be completed by patient advocacy services (PAS) and management, which will have separate and distinct purposes in the investigation process. Advocacy will independently determine the need for an investigation and if evidence exists to conclude a patient's right infringement has occurred. Management will determine what actions are needed to correct and prevent reoccurrence if warranted. ... VIII. Notification of DHSR/HCPR (Division of Health Service Regulation / Health Care Personnel Registry) A. The hospital reports to DHSR/HCPR if allegations of the following affect health care personnel, i.e. certified nursing assistants (CNAs) or other unlicensed direct care workers: 1. Abuse ... B. Initial reports are made by designated management within twenty-four (24) hours of being made aware of the allegation with final results of investigations submitted within five (5) working days. ..."

1. Review of Patient #3's open medical record revealed a 43 year-old male that was admitted 02/05/2015 under petition for involuntary commitment (IVC) for schizoaffective disorder, bipolar type. Review of nursing notes dated 02/18/2015 at 1832 recorded that the patient stated he was hit in the nose by a staff member around 1740. Review revealed a medical assessment was completed by a Physician's Assistant on 02/18/2015 at 1835 that recorded the patient had made an unwitnessed allegation of abuse.

Review of an incident log revealed Patient #3 alleged he was abused by a staff member in the hallway on 02/18/2015 at 1745.

Interview on 03/18/2015 at 1015 with Patient Advocate #13 revealed he was on call on 02/18/2015 when he received a call from the Unit nurse who reported that Patient #3 had alleged he was assaulted by a second shift male staff member. The advocate stated the nurse reported there were witnesses and he obtained written statements from the staff members involved. The advocate reported that the allegation was unsubstantiated based on the witness statements and lack of evidence. Interview revealed the alleged abuse allegation was not reported to the North Carolina Health Care Personnel Registry (HCPR).

Interview on 03/19/2015 at 1620 with Patient Advocate Director #14 revealed Patient advocate #13 got the report that Patient #3 stated he was assaulted by a staff member and was told that there were witnesses that said that it was not true. Interview revealed written statements were obtained by staff and it was determined that it was not a credible allegation. Interview revealed the allegation of staff to patient abuse was not reported to the HCPR because it was not felt to be a credible allegation. The staff member stated "We make the determination what to report."

Telephone interview on 03/20/2015 at 1015 with staff member #15 with the Health Care Personnel Registry revealed "Any allegation of staff abuse has to be reported. Even if they can't substantiate it, it has to be reported. It is a requirement. All allegation of staff to patient abuse are to be reported."



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2. Review of Pt # 2's closed medical record revealed a 13 year old patient who was admitted 06/08/2014. Review of the Psychiatric Assessment, revised 06/09/2014 at 1321 revealed a "Diagnostic Impression" of "...Mood disorder (psychological disorder characterized by disturbance of the mood, such as depression or bipolar disorder)....Conduct disorder (disorder involving a pattern of disruptive or violent behavior or trouble following rules)....Attention-deficit hyperactivity disorder (ADHD - involving attention difficulty, impulsiveness). ..."
Review of a Hospital Document, dated 07/02/2014, revealed Pt # 2's guardian/mother reported that Pt # 2 stated "...that a staff member (first name) had grabbed his arm and pushed him down the hall during a conflict pt was having with a peer. ..." Review revealed Advocate # 13 and Supervisor # 18 met with the patient to gather information and "...(Pt #2) reported that CNA (Certified Nursing Assistant) (first and last name) had grabbed pt's arm when pt was 'rough housing' with a peer. (Pt # 2 last name) demonstrated CNA (last name) redirecting pt away from the conflict. (Pt # 2 last name) did not report or demonstrate anything abusive. ..."
Interview with Advocate # 13 on 03/19/2015 at 1625 revealed that Pt # 2 reported he was grabbed and pushed down the hall. Interview revealed he asked Pt # 2 to demonstrate what happened and when the patient did so, he demonstrated that the CNA put his hand on him and guided him down the hall, not in a forceful way. Interview revealed "...What was demonstrated was not abuse or a restrictive intervention." Because of this finding, interview revealed, there was nothing further done.
Interview on 03/20/2015 at 1130 with Director # 14 revealed the allegation and investigation was not reported to the Health Care Personnel Registry. Interview revealed the advocate spoke with Pt # 2 and determined from the conversation and demonstration that there was no abuse. Interview revealed that based on this, no report was made.
NC00100606, NC00100629, NC00098314, NC00104276, NC00096875