HospitalInspections.org

Based on document review and interviews it was revealed the facility failed to ensure all staff follow their own policy to report allegations/complaints of abuse in one (1) of one (1) records reviewed of a patient with an allegation of abuse (patient #1). This failure to ensure all staff follow the facility policy to report allegations of abuse can negatively impact all patients if all staff don't report abuse in any form per policy and the law.

1. An interview with the Clinical Manager (CM) of the unit the patient was admitted to at the facility on 7/1/19 at 10:45 a.m. revealed she did know patient #1 and remembered her. She received a voicemail on 6/5/19 and returned the call to patient #1's guardian. The guardian and the patient both stated to her the patient might have had sex at the facility. The CM stated she asked for specific information but the patient said she didn't remember anyone in her room. She said it must have happened at night because the next day she bled. The patient could not pinpoint a specific date. The CM felt the statements didn't add up and the details were vague. She told them if they had concerns after the doctor's appointment to call her back. There was no return call. She did not document any of her investigation/conversation. She did not report the allegation of abuse to the proper authorities. She didn't fill out an incident report or report to the Quality Director. She stated, "I should have reported it."

2. A review of the hospital policy titled Abuse Reporting-Adult/Child and documenting, last revised 9/2018, revealed in part for the procedure if abuse is identified: "If the staff is uncertain of the need to report, the case will be staffed with the Therapy Services Director, Program Manager or Nurse Supervisor. The staff member receiving the information regarding any case of suspected or reported abuse or neglect, will report this information to Adult (APS) or Child Protective Services (CPS)...the staff will complete a CPS/APS Reporting form." A review of the hospital policy titled Allegation of Patient Abuse, last revised 6/7/2018, stated in part: "The individual receiving an allegation of abuse will obtain and carefully document all pertinent information regarding the complaint...complete an incident report...and the Program Manager, Nurse Supervisor and/or Director of Nursing and Patient Care Services, Director of Quality and Risk Management will fully investigate the allegation beginning with an interview of the patient, alleged perpetrator, witness...A written report including recommendations regarding the allegations will be completed...within twenty-four (24) hours following receipt of the allegations."

3. In an interview with the Director of Quality and Risk Management on 7/1/19 at approximately 2:10 p.m. she stated the Quality Department had not investigated the allegation of abuse because the staff had not reported it to them nor filed a written complaint/incident.

Based on document review and interviews it was revealed the facility failed to ensure all staff follow their own policy to report allegations/complaints of abuse in one (1) of one (1) records reviewed of a patient with an allegation of abuse (patient #1). This failure to ensure all staff follow the facility policy to report allegations of abuse can negatively impact all patients if all staff don't report abuse in any form per policy and the law.

1. An interview with the Clinical Manager (CM) of the unit the patient was admitted to at the facility on 7/1/19 at 10:45 a.m. revealed she did know patient #1 and remembered her. She received a voicemail on 6/5/19 and returned the call to patient #1's guardian. The guardian and the patient both stated to her the patient might have had sex at the facility. The CM stated she asked for specific information but the patient said she didn't remember anyone in her room. She said it must have happened at night because the next day she bled. The patient could not pinpoint a specific date. The CM felt the statements didn't add up and the details were vague. She told them if they had concerns after the doctor's appointment to call her back. There was no return call. She did not document any of her investigation/conversation. She did not report the allegation of abuse to the proper authorities. She didn't fill out an incident report or report to the Quality Director. She stated, "I should have reported it."

2. A review of the hospital policy titled Abuse Reporting-Adult/Child and documenting, last revised 9/2018, revealed in part for the procedure if abuse is identified: "If the staff is uncertain of the need to report, the case will be staffed with the Therapy Services Director, Program Manager or Nurse Supervisor. The staff member receiving the information regarding any case of suspected or reported abuse or neglect, will report this information to Adult (APS) or Child Protective Services (CPS)...the staff will complete a CPS/APS Reporting form." A review of the hospital policy titled Allegation of Patient Abuse, last revised 6/7/2018, stated in part: "The individual receiving an allegation of abuse will obtain and carefully document all pertinent information regarding the complaint...complete an incident report...and the Program Manager, Nurse Supervisor and/or Director of Nursing and Patient Care Services, Director of Quality and Risk Management will fully investigate the allegation beginning with an interview of the patient, alleged perpetrator, witness...A written report including recommendations regarding the allegations will be completed...within twenty-four (24) hours following receipt of the allegations."

3. In an interview with the Director of Quality and Risk Management on 7/1/19 at approximately 2:10 p.m. she stated the Quality Department had not investigated the allegation of abuse because the staff had not reported it to them nor filed a written complaint/incident.