HospitalInspections.org

Based upon interview and record review the facility failed to protect the rights of 1 of 1 patients (Patient #1) to be free of abuse in a sample of 10 reviews and failed to protect Pt. #1 from further abuse after an allegation of abuse by Personal Care Tech A was reported.

Findings include:

The facility failed to protect Patient #1 while the investigation was being conducted. See tag A0145

The facility staff failed to report the alleged incident of abuse/Caregiver Misconduct to the supervisor per facility policy. See tag A0145.

The facility failed to thoroughly investigate and provide documentation of the investigation per facility policy. See tag A0286.

The facility failed to provide annual education on Abuse and Neglect per facility policy. See tag A0145.

Based on Interview and record review, facility staff failed to report and investigate allegations of patient abuse per policy, and failed to take immediate action by removing the accused caregiver from patient care in order to protect patients from abuse in 1 of 1 patient abuse allegations (Patient #1), in a sample of 10 patient records reviewed. The facility also failed to educate staff in abuse and neglect policies and procedures every year per policy. Failure to take immediate steps to protect patients after allegations of abuse resulted in the potential for continued serious harm for Patient #1, and has the potential to affect all patients receiving care at this facility.



Findings Include:


Review of facility policy #10668949, titled, "Investigation Alleged Patient Abuse Procedure," revealed, "All allegations or incidents are thoroughly investigated internally, and documented by the assigned investigator. These are the steps in the investigation process: A.....At the time a report of alleged mistreatment is received, the supervisor on duty and in charge of the area begins the preliminary investigation. The following must be completed as applicable: 1. The supervisor will obtain initial information from the person who became aware of/reported the incident or allegation, in order to determine the scope of the incident and which area(s) and patient(s) or employee(s) may have information about it. If applicable, the supervisor will remove the accused employee(s) from the patients involved. a. The supervisor will interview the patient allegedly mistreated to gather information about the incident, and obtain the patient's statement regarding the allegation. If applicable the supervisor will: i. determine if there is evidence of physical injury and ensure medical examination if needed.....5. When the supervisor has obtained as much information as they are able to, they will contact the Human Resource Director or Institute Deputy Director if during normal business hours, or the Administrator on Duty at all other times."

Review of facility policy #201.1 titled, "Investigating and Preventing Patient Abuse, last revised 11/2021 revealed, "The (Department) and (Facility) have a zero tolerance policy for unacceptable behavior, including abuse, neglect, and/or misappropriation of patient property......This policy is intended to provide safeguards for an abuse-free environment; to ensure that allegations of abuse, neglect and/or misappropriation are investigated in a timely and objective manner.....2.....work rules 2 and 3 state all (Department) employees are prohibited from:....B. abusing, striking, or deliberately causing mental anguish or injury to patients, inmates, or others......At the time a report of alleged mistreatment is received, the supervisor on duty and in charge of the area begins the preliminary investigation. The supervisor will also consult with AOD (Administrator of the day) to determine if immediate action needs to be taken.....C Training of employees: 1. In addition to the initial NEO (New Employee Orientation) training....employees receive annual retraining on policies related to patient safety and prevention of abuse, neglet and misappropriation, during mandatory Annual Health and Safety Training."

Review of facility Policy #201.03, titled, "Elder/Adult-at-Risk Reporting Procedure," last revised 11/2021 revealed, "The purpose of this policy is to help ensure that patients, especially those who are vulnerable, are not subject to abuse and to delineate the range of behaviors that constitutes abuse; neglect of patients (the elderly and the adult-at-risk) and provide procedures and guidelines for decisions regarding mandatory and non-mandatory reporting...AC. 1. Any employee who reasonably believes that elder abuse has occurred....must report this to his/her supervisor....The Report of Suspected Abuse/Neglect (F-00531) should also be immediately completed and filed in the patient's medical record. Documentation shall be completed as soon as possible after filing the report but before the employee leaves at the end of that shift."

Per review of Facility Caregiver Misconduct Report, on 6/1/2022 at 4:45 PM Patient #1 entered the shower room and Psychiatric Care Technician (PCT) A put hands on Patient #1. Patient #1 hit PCT A and PCT A hit Patient #1 on the shoulder loudly. PCT B witnessed this and reported that PCT A hit Patient #1 to RN C. RN C did not report the alleged abuse to the supervisor. PCT B later reported the abuse to Patient Care Supervisor (PCS) E.

In an interview on 07/06/2022 at 10:15 AM with ADON (Assistant Director of Nurses) F when asked about the investigation and follow up that happened with the incident on 06/01/2022 at 4:45 PM, ADON F stated, "There was an issue with how this was reported. It was reported to the PCT supervisor on PM/NOC (nights) at 10:30 PM, (He/she) reported it to the NOC shift RN supervisor and notified the ADON in the AM when they came in.

In an interview with ADON F on 07/06/2022 at 3:25 PM when asked what should have happened when this abuse was reported, ADON F stated, "When it was reported to the RN, the RN should have contacted the supervisor, removed the employee, done an assessment, this should have been done at the time it was reported."

In an interview with RN G on 07/06/2022 at 4:00 PM when asked if PCT A continued to work with Pt. #1, RN G stated, "My understanding is that (PCT A) continued to work with Pt. #1, I don't know what happened when they needed breaks, I do know (she/he) was assigned to that patient." When asked if the provider was notified, RN G stated, "No provider notification happened during the night, they were seen by the provider the next morning. I emailed (ADON F) in the morning of the incident."

Review of Pt. #1 medical record on 07/07/2022 at 8:20 AM with EHR (Electronic Health Record) RN (Registered Nurse) U revealed no documentation present of the alleged incident (abuse allegation) on 06/01/2022 at 4:45 PM, no evidence of assessment of injury following the incident, no notification of the provider regarding the incident. Patient care assignment for the Patient Care Tech (PCT) revealed PCT A continued to care for Pt. #1 in a 1-1 assignment for the remainder of the shift until 10:30 PM.

In an interview with EHR (Electronic Health Record) RN U on 07/07/2022 at 8:45 AM, when asked if that was correct, that there was no evidence of a nursing assessment, no evidence of notification of the provider and no documentation of the incident present. RN U stated, "There doesn't appear to be."

In an interview with RN C on 07/07/2022 at 11:10 AM, RN C stated, "It (alleged abuse) was reported to me by a PCT, that another PCT had hit a patient. I don't know if they saw it or heard it, a slap, not sure what happened. I told the PCT to let the PCS supervisor know. Then I left for the night when my replacement came." RN C stated (he/she) did not investigate the incident and did not take any action to protect Patient #1 or remove PCT A from providing direct patient care to Patient #1. Per RN C, PCT A was assigned to care for Patient #1 as a 1 to 1 (close supervision) and continued that assignment for the remainder of A's shift until 10:30 PM, more than 5 hours after PCT A was observed striking Patient #1.

In an interview with ADON F on 07/07/2022 at 11:20 AM when asked what training staff receive regarding abuse and neglect, investigation and reporting, ADON F stated, "The last facility abuse/neglect education was provided 12/2020. We did no education in 2021, we missed it, typically we do this every year, not sure what happened in 2021."

Based on interview and record review the facility failed to fully investigate, analyze and implement preventative actions in 1 of 1 patients (Patient #1) allegations of abuse.

Findings Include:


Review of Facility Policy #205.02, titled, "Incident Reporting," last revised 12/2020, revealed, "It is required that all unexpected or unusual events that are harmful or potentially harmful to patients.....are reported to management. This information is analyzed....to identify trends and opportunities for improvement. Specific types of incidents involving a patient should be documented on Patient Incident form...Incidents-are unexpected or unusual events that are harmful or potentially harmful or have an unfavorable or potentially unfavorable outcome......Critical Incidents-are serious events wherein (facility name) has evidence to support or other reason to believe one of the following has occurred......Injury or potential injury to a patient/client that occurs as the result of alleged neglect or mistreatment by staff...The following types of incidents must be reported....any unexpected or unusual significant incident or injury witnessed or not witnessed....A. Any (facility name) employee who witnesses or is otherwise made aware of an incident involving a patient....must report the incident to the immediate supervisor. 1. An incident involving a patient: a. shall be documented on Patient Incident Form....and enter the information on the 24 hour report. i. A patient incident form should be completed for every incident.....iv. details for all injuries to all patients involved in the incident need to be addressed on the incident report.....b. The RN is to notify the provider if appropriate and is to complete the patient incident form the same shift the incident occurred. i. RN will forward incident form to attending provider for review. c. If another staff has information as a witness that the RN did not observe, they shall document the information in a progress note the same shift as the incident.....D. If a Critical Event were to occur.....1. The facility Director or designee shall be notified and should assess the need for staff directly involved in the event to be assigned to alternative work....pending completion of internal review....3. The internal investigation of the event is to be immediately started if no external law enforcement investigation is initiated....8. The review of the incident shall be written and include the following components: a. Background and history of the incident, b. Relevant patient, resident, or inmate details, c. Details of staff action, d. Identification of strengths and areas of improvement, e. Plan for correction, if any, including timeline. 9. Results of the internal investigation are to be reviewed by facility Director, Division Administration, and others as necessary before closing the event and returning employees to their normal assignment."

Per review of Facility Caregiver Misconduct Report, on 6/1/2022 at 4:45 PM Patient #1 entered the shower room and Psychiatric Care Technician (PCT) A put hands on Patient #1. Patient #1 hit PCT A and PCT A hit Patient #1 on the shoulder loudly. PCT B witnessed this and reported that PCT A hit Patient #1 to RN C. RN C did not report the alleged abuse to the supervisor. PCT B later reported the abuse to Patient Care Supervisor (PCS) E.

In an interview on 07/06/2022 at 10:15 AM with ADON (Assistant Director of Nurses) F when asked about the investigation and follow up that happened with the incident on 06/01/2022 at 4:45 PM, ADON F stated, "There was an issue with how this was reported. It was reported to the PCT supervisor on PM/NOC (nights) at 10:30 PM, (He/she) reported it to the NOC shift RN supervisor and notified the ADON in the AM when they came in.

In an inteview with ADON F on 07/07/2022 at 11:20 AM, when asked if there was an incident report or investigation completed when this allegation of abuse occurred, ADON F stated, "I don't believe there was, the investigation didn't happen. This was a contracted employee, the matter was handled, and (he/she) was terminated. When asked why an investigation wasn't done Staff F stated, "This procedure speaks to FTE (Full Time Equivalent) employees. You're correct we didn't follow the policy and we looked at it differently because it was a contract employee. There was no information to indicate more than an isolated incident." When asked how can you know it was an isolated incident versus systemic when no investigation was done or root cause analysis completed, ADON F stated, "Understood."