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Based on review of policies and procedures, hospital documents and medical records, and interviews with hospital staff, the hospital failed to follow its policy to ensure abuse did not occur. For one of one patient (Patient #3), the hospital staff did not follow the hospital's procedure when allegations of abuse by staff occurred.

Findings:

1. The hospital's policy, PCM #200, Abuse/Neglect (Child, Domestic, Dependent Adult/Elderly, Sexual) with an effective date of 06/23/2010, stipulates all cases of reported abuse would be investigated. The policy documents that the patient's nurse is to notify her immediate supervisor, the Case Management department and the unit Manager.

2. The Progressive Care Unit Manager told the surveyors on the morning of 02/23/2011 that she had not had any reports of allegations of patient abuse by staff.

3. Staff I told the surveyors on 02/23/2011 at 1055 that Patient #3 and Patient #3's representative reported that the patient had been "hit" by an aide and the aide had "been rough with (the patient)." When asked what she did about this, she replied she reported it to the charge nurse on the unit. She did not report that she examined the patient for any evidence of injury to the patient.

4. Staff J told the surveyors on 02/23/2011 at 1325 that Staff I had reported the allegation of patient abuse by Staff K to her. She stated that since Staff I stated she had been with the aide and did not witness abuse; and since the patient was confused at times, she did not report the allegation to anyone else. She stated she talked with the family and it was decided to reassign the aide. She did not report that she examined the patient for any evidence of injury to the patient.

5. Review of incident/occurrence reports, the grievance log, and Patient #3's medical record did not contain documentation that an allegation of abuse had occurred or that the patient was assessed for physical harm. Staff I and J told the surveyors on 02/23/2011 that they had not completed an incident report.

Based on review of the hospital's documents and interviews with staff, the hospital failed to ensure the infection control practitioner developed and implemented an ongoing infection control program based on nationally recognized infection control guidelines and designed to identify, prevent, control and investigate infections and communicable diseases of patients and personnel.

Findings:

1. On the morning of 2/21/11 surveyors reviewed the hospital's infection control log. Patient #5 was listed on the log. The documentation for patient #5 indicated "HAI" (hospital acquired infection) was written on the log with a line drawn through and above HAI was written "POA" (present on admission). On the afternoon of 2/21/11 surveyors spoke with staff E the infection prevention specialist. Staff E told surveyors Patient #5's infection was initially identified as a HAI but when Staff E went to investigate the infection, a physician caring for the patient told Staff E the infection was POA. There was no documentation in the chart by this physician indicating the infection was present on admission. Staff E told surveyors there was no further review of care and no review of the information regarding Patient #5 in the infection control meeting.

2. On the afternoon of 2/22/11, Staff E told surveyors Patient #5's infection was determined to be POA because the patient had a bowel surgery and later developed a blood stream infection of VRE (vancomycin resistant enterococci). Staff E told surveyors the growth of VRE indicated the patient was colonized with the infection prior to admission. Patient #5's chart did not indicate any cultures had been performed on the patient prior to arrival to establish the patient had been colonized with VRE. There was no documentation in the chart which reflected the patient had an infection or microbial colonization prior to admission. There was no documentation in the history and physical the patient had been treated for this infection or was currently being treated for this infection at the time of admission.

3. These findings were reviewed with administration during the exit conference on 2/23/2011. No further documentation was provided.