HospitalInspections.org

Based on document review and interview it was determined that the Hospital failed to provide care in a safe setting and to protect and promote patient rights by failing to follow the abuse protocol during an investigation of an allegation of abuse. As a result, the Condition of Participation, 42 CFR 482.13 Patient Rights was not in compliance.

Findings include:

1. The Hospital failed to ensure that Pt. #3 did not suffer injury while hospitalized. (A-144).

2. The Hospital failed to ensure that a thorough investigation for an abuse allegation was conducted. (A-145).

Based on document review and interview, it was determined that for 1 of 2 (Pt. #3) patient records reviewed for abuse allegations, the Hospital failed to ensure care in a safe setting. As a result Pt. #3 suffered a swollen bruised eye and missing tooth.

Findings include:

1. On 8/2/2022, the Hospital's policy titled, "Patient Rights and Responsibilities" dated 12/12/2019, was reviewed. The policy indicated "....2. Patients have the right to be assured of their reasonable safety while a patient in the hospital...E. Patient Safety - 1. [Hospital system name] supports the right of patients and families to be in a safe environment..."

2. On 8/2/2022, Pt. #3's clinical record was reviewed. Pt. #3 was admitted on 7/13/2022, with a diagnosis of congestive heart failure.

-A progress noted dated 7/17/2022 at 10:30 AM, authored by a Registered Nurse (E #2), included, "At start of the shift redness noted to right eye, and right lid, with front tooth missing. Lower lip looks dark/bruised from the patient biting per report from CNA [Certified Nursing Assistant] ...Patient is very restless, aggressive, swing arms at staff, and gets combative ...Restraints applied around 0930 am, and perfect serve MD to obtain order. RN called daughter to notify her of restraints applied. Daughter threatened this RN that she is on her way up to the unit since 'someone tied her mother down, and busted her front teeth.' Charge RN notified. Security called up to unit and House supervisor notified and came to bedside. Daughter found tooth on the floor in a pile of dirty linen in the room. RN notices a metal piece/screw noted to the found front teeth. All other parties involved ..."

-The Public Safety incident report dated 7/17/2022 at 8:45 AM, authored by a Public Safety Officer (E #4), included, "In summary, reporting officer ...was called to room ...by medical staff stating that family was upset because patient [Pt. #3] right eye was swollen and discolored and her lips were swollen with a front top implant tooth missing. Family immediately felt that she had been abused by medical staff ...[Family] stated when he left at approximately 1700 hours on July 16 2022 she [Pt. #3] looked fine her tooth was in place and she did not have a swollen eye or lip ...Patient [Pt. #3] stated that someone came in her room (she didn't know who) and tried to draw blood. She said that they could not get blood and they went to the other side of the bed and tried her other arm and she stated she told them no, no more...She then stated that someone hit her in the face..."

3. On 8/3/3022 at 9:03 AM, an interview with a Public Safety Officer (E #4). E #4 stated that on 7/17/2022, during the day shift she was called to the unit where Pt. # 3 was located. E #4 stated that Pt. #3's right eye was black and swollen and the top lip was swollen and a front tooth was missing. E #4 stated that Pt. #3 stated that someone hit her.

4. On 8/3/30222 at 9:56 AM, an interview was conducted with a Registered Nurse (RN/E #2). E #2 stated that she was Pt. #3's RN on 7/17/2022, during the day shift. E #2 stated that she received Pt. #3 on 7/17/2022, with a red and swelling right eye and a missing tooth. E #2 stated that she does not know how Pt. #3 sustained the injuries.

Based on document review and interview it was determined that for 1 of 2 (Pt. #3) patient records reviewed for abuse allegation, the hospital failed to ensure that the patient has the right to be free from all forms of abuse by failing to conduct a thorough abuse investigation.

Findings include:

1. On 8/2/2022, the Hospital's "Investigation Protocol for Alleged Team Member Misconduct (February 2021) was reviewed. The Protocol included, "...Interviewing Witness - After interviewing the complainant, the next step is to interview witnesses or others who may have information that would support or refute the complaint..."

2. On 8/2/022, Pt. #3's clinical record was reviewed. Pt. #3 was admitted on 7/13/2022, with a diagnosis of congestive heart failure. Pt. #3 was discharge home on 7/20/2022.

-A progress noted dated 7/17/2022 at 10:30 AM, authored by a Registered Nurse (E #2), included, "At start of the shift redness noted to right eye, and right lid, with front tooth missing. Lower lip looks dark/bruised from the patient biting per report from CNA [Certified Nursing Assistant] ...Patient is very restless, aggressive, swing arms at staff, and gets combative ...Restraints applied around 0930 am, and perfect serve MD to obtain order. RN called daughter to notify her of restraints applied. Daughter threatened this RN that she is on her way up to the unit since 'someone tied her mother down, and busted her front teeth.' Charge RN notified. Security called up to unit and House supervisor notified and came to bedside. Daughter found tooth on the floor in a pile of dirty linen in the room. RN notices a metal piece/screw noted to the found front teeth. All other parties involved ..."

3. -The Public Safety incident report dated 7/17/2022 at 8:45 AM, authored by a Public Safety Officer (E #4), included, "In summary, reporting officer ...was called to room ...by medical staff stating that family was upset because patient [Pt. #3] right eye was swollen and discolored and her lips were swollen with a front top implant tooth missing. Family immediately felt that she had been abused by medical staff ... [Family] stated when he left at approximately 1700 hours on July 16 2022 she [Pt. #3] looked fine her tooth was in place and she did not have a swollen eye or lip ...Patient [Pt. #3] stated that someone came in her room (she didn't know who) and tried to draw blood. She said that they could not get blood and they went to the other side of the bed and tried her other arm and she stated the she told them no, no more. While speaking on the matter she was visibly falling in and out of sleep and slurring words. She then stated that someone hit her in the face..." The incident report included interviews with Pt. #3's day shift bedside nurse, the night shift certified nursing assistant and the night shift charge nurse. The incident report included documentation that the local police department were called and arrived to file a police report and that Pt. #3 was transferred to another floor/unit following the incident. The incident report included, " ...This report will be pending ..." The incident report lacked documentation that Pt. #3's night shift RN (E #16) was interviewed regarding the abuse allegation.

4. The Hospital Patient Abuse Report form dated 7/19/2022, included, interviews with Pt. #3, Pt. #3's daughter, and Pt. #3's RN on 7/17/2022 (day shift). The report lacked documentation of an interview with E #16, the RN who took care of Pt. #3, on 7/16/2022 - 7/17/2022, during the night shift.

5. The Human Resources investigation dated 7/27/2022 (ten days after the allegation), included, additional staff interviews with Hospital Phlebotomist who worked on 7/16/2022 and 7/17/2022, with Pt. #3. The report concluded that the Hospital was not able to substantiate any of the staff interviewed hit Pt. #3.

6. On 8/3/2022 at 1:47 PM, an interview was conducted with a Registered Nurse (E#16). E #16 stated that he does not recall Pt. #3. E #16 stated that he has not been interviewed by the Hospital regarding an allegation of abuse.