HospitalInspections.org

Based on record review and interview the facility failed to ensure there are policies in place to protect patients from potential assault by staff and completion of medical records in emergency services in 1 of 1 staff incident (C) and 6 of 10 medical records reviewed (2, 3, 5, 6, 8 and 10); and complaint process is completed per policy in 2 of 3 complaints reviewed (#11 and #12).

Findings include:

1. The facility failed to have policies regarding and ensuring patients are protected from assaults by staff during an alleged assault investigation. See Tag 271.

2. The facility failed to ensure complaints are completed per policy in 2 of 3 complaints reviewed. (#11 and #12). See Tag 271.

2. The facility failed to ensure there are policies in place for emergency room medical record documentation. See Tag 302.

The cumulative affect of these deficiencies directly affect 3 patients (#2, #11 and #12), and potentially affect all patients treated at the facility.

Based on record review and interview the facility failed to ensure policies are in place to provide for safety of patients during an investigation of alleged patient assault by staff, in 2 of 2 patients (1 and 2) and 1 of 1 staff (C). And the facility failed to ensure the complaint process is completed per policy in 2 of 3 complaints reviewed. (#11 and #12)

Findings include:

Example of patient safety:

Per review on 10/5/19 at 2:30 PM of facility timeline document related to an investigation of Nurse C sexually assaulting Patient #1 on 7/19/15, it revealed the facility was notified by the local police on 7/22/15 of the assault that occurred in the Emergency Department. Per the document, the police asked the facility to not interview Nurse C until they spoke with him/her. On 7/28/15, the police told the facility Nurse C denied the allegation and gave the okay to talk to Nurse C. On 7/29/15 the timeline included the statement "Discussed (Nurse C)'s reaction and denial of complaint."

In interview with President D on 10/5/15 at 12:15 PM, President D confirmed the police wanted to talk with Nurse C before the facility did, and asked them to wait to talk with Nurse C. At the time, President D said they did not want to compromise the police investigation. President E said they took no action with Nurse C, other than starting to investigate the incident, and allowed Nurse C to continue working in the emergency department during the investigation. President C said there is no policy for actions to take during an investigation.

Per review of the facility staffing schedule for July 2105, Nurse C was scheduled as the only nurse on the night shift in the emergency department on 7/22/15, 7/24/15 and 7/27/15.

On 8/4/15 the facility was notified by the police of another sexual assault by Nurse C to Patient #2 on 7/27/15. The facility's investigation on into the allegation included Nurse C stating s/he gave Patient #2 a back rub, moved on to a stomach rub and claimed Patient #2 grabbed his/her hand and pushed it down Patient #2's pants. Per President D in interview on 10/5/15 at 12:15 PM Nurse C was placed taken off the schedule during the investigation and terminated on 8/13/15.

Example of complaint process:

Review of facility policy titled Complaint and Grievance revised 7/13 states under F. "...Individuals filing a grievance will be sent a follow-up letter upon completion of the investigation into the grievance..."

Per review on 10/5/15 at 2:50 PM of a complaint filed by Patient #11 on 7/19/15 regarding rude emergency room staff, the complainant was contacted by the Chief Nursing Officer and discussed at the 8/13/15 Patient Care Meeting. Patient #11 was called, thanked and the record stated "No further action needed." There was no letter sent to Patient #11 with the results of the investigation. This is confirmed in interview with Director of Nursing E on 10/5/15 at 2:50 PM, who was unaware a letter should be sent, and it was not clearly documented the patient requested a letter to not be sent.

Per review on 10/5/15 at 2:50 PM of a complaint filed by Patient #12 on 7/26/15 regarding a physician not listening, the complainant was contacted by the Chief Nursing Officer and discussed at the 8/13/15 Patient Care Meeting. Patient #12 was called, thanked and the record stated "The patient did not request anything else but was happy with the phone call." This is confirmed in interview with Director of Nursing E on 10/5/15 at 2:50 PM, who was unaware a letter should be sent, and it was not clearly documented the patient requested a letter to not be sent.

Based on record review and interview the facility failed to ensure medical records are complete with dates and times and assessments by staff in 6 of 10 medical records reviewed (#2, 3, 5, 6, 8 and 10).

Findings include:

Patient #2's medical record review revealed Patient #2 arrived in the Emergency Department on 7/27/15 at 10:28 PM with a complaint of a headache, there is no documentation of when the physician saw the patient for examination.

Patient #3's medical record review revealed Patient #3 arrived in the Emergency Department on 7/31/15 at 3:54 PM with a complaint of chest pain. There is no documentation of when the physician was notified of Patient #3's arrival nor when the physician saw Patient #3 for examination.

Patient #5's medical record review revealed Patient #5 arrived in the Emergency Department on 7/22/15 at 5:52 PM with a complaint of chest pain. There is no documentation of when the physician was notified of Patient #5's arrival nor when the physician saw Patient #5 for examination.

Patient #6's medical record review revealed Patient #6 arrived in the Emergency Department on 7/13/15 at 2:19 PM with a complaint of back pain. There is no documentation of when the physician was notified of Patient #6's arrival nor when the physician saw Patient #6 for examination.

Patient #8's medical record review revealed Patient #8 arrived in the Emergency Department on 7/9/15 via ambulance after a motor vehicle accident. There is no documentation of when the patient arrived, the nursing assessment, when the physician was notified of Patient #8's arrival nor when the physician saw Patient #8 for examination.

Patient #10's medical record review revealed Patient #3 arrived in the Emergency Department on 727/15 at 2:19 PM with a complaint of back pain. There is no documentation of when the physician was notified of Patient #10's arrival.

The above findings are confirmed in interview with Director of Nursing E on 10/5/15 between 11:10 AM and 2:32 PM, who stated the computer system is new and there are no policies to address documentation in the computer record yet. Director of Nursing E said the arrival time, notification and exam times by the physician as well as the assessment documentation should be in the medical record.