HospitalInspections.org

Based on a review of facility documents, medical records (MR), and staff interviews (EMP), it was determined that Wellspan Ephrata Community Hospital failed to remove an employee from patient care who was being investigated for abuse and allowed the employee to continue to work with the patient, with whom the alleged abuse took place.

Based on the seriousness of the non-compliance and the effect on patient outcome, the facility failed to substantially comply with this Condition.

Cross reference:
482.13(c)(3) Patient Rights: Free from Abuse/harassment.

Based on review of facility documents, medical records (MR), and employee (EMP) interviews, it was determined the facility failed to ensure an adolescent patient was protected from abuse/harassment for one of ten medical records reviewed (MR10).

Findings include:

Review on May 3, 2022, of the facility's "Human Resources Policy, Policy Number: ER-50," reviewed/revised November 8, 2019, revealed "Subject: Corrective Action Purpose: To ensure a safe healthy and secure environment, it is important that Wellspan Health establish certain guidelines regarding the various aspects of our operation. The rules we have established are designed not to restrict any one individual, but rather to be equally fair and consistent to all. Our guidelines enable all employees to know not only what is expected of them, but also what they can expect from others. ... B. Corrective Action Process In circumstances where it is likely that an investigation needs to be conducted involving an employee, Human Resources should be contacted to discuss whether an immediate paid administrative leave is appropriate. During non-business hours, the House Supervisor, Administrator on-call (AOC), and/or direct leader on-call should be contacted for immediate guidance with follow-up to Human Resources on the next business day. Note: In the case of alleged patient abuse or similar instances of serious allegations, the employee being accused should immediately be placed on paid administrative leave upon report and pending investigation ... "

A review on May 3, 2022, of MR10 revealed the adolescent patient was brought to the Emergency Department (ED) on April 6, 2022, after self-harm was witnessed at home. The patient was involuntarily committed and was placed on High Risk Observation (HRO). HRO required a one to one sitter and video monitoring.

Interview conducted on May 2, 2022, with EMP2 revealed EMP3 was the required one to one sitter for MR10. EMP2 witnessed the following on the video monitoring on April 7, 2022. EMP3 was sitting on the side of the bed leaning over the patient who was lying in bed. EMP3 was stroking the patient's arms, face and torso. EMP2 requested EMP4 to view the video monitor. Per EMP2, EMP4 stated what was seen on the video monitor was not appropriate behavior. EMP4 went into the patient room and told EMP3 to come out of the room. EMP2 attempted to find the Charge Nurse and EMP6. EMP2 was unsuccessful in finding these employees before punching out at 2315. At approximately 0100 on April 8, 2022, EMP2 called EMP5 stating this event could not wait to be reported. EMP2 provided the details of what occurred to EMP5. EMP5 took down the concerns and stated the information would be given to EMP6, the house supervisor, in the morning.

Interview conducted on May 3, 2022, with EMP4 revealed EMP4 asked MR10 on April 7, 2022, if the patient was okay. The patient stated they just wanted EMP3 to leave the room. EMP4 asked EMP3 what was happening. EMP3 stated they were just trying to get the patient to talk. EMP3 then went back to monitoring MR10 and was never asked to leave the area/facility. EMP3 finished shift.

On May 5, 2022, a review of the Staffing schedule for April 1, 2022, through April 30, 2022, revealed that EMP3 was on the staffing sheet and assigned to MR10 on April 10, 2022, following the alleged incident of April 7, 2022.

Telephone interview with EMP5 on May 4, 2022, at 0953 revealed EMP3 attempted to make contact with MR10 on April 12, 2022. The investigation was completed on April 15, 2022, and EMP3 was terminated on April 18, 2022.