HospitalInspections.org

Based on interview and document review, the facility failed to develop and implement a policy that protected patients from an alleged abuser while an investigation was in progress, resulting in the potential for unsatisfactory outcomes for any of the 160 patients residing in the facility. Findings include:

See specific tag A-0145.

Based on interview and document review, the facility failed to develop and implement a policy that protected patients from an alleged abuser while an investigation was in progress, resulting in the potential for unsatisfactory outcomes for any of the 160 patients residing in the facility. Findings include:

On 09/20/21 at approximately 1215 during an interview, Clinical Leadership Staff B indicated recipient rights staff were responsible to investigate all patient complaints related to abuse or neglect and made recommendations to clinical leadership based on the findings of the investigation. Staff B was not aware of any abuse/neglect policy or procedure that required automatic suspension of the accused staff during the abuse/neglect investigation.

On 09/20/21 at approximately 1320 and 1340 during interviews, the Interim Chief Nursing Officer (RN D) indicated it was possible that staff accused of patient abuse or neglect could be reassigned to provide direct patient care on other units in the hospital prior to the completion of an abuse/neglect investigation. RN D indicated based on the magnitude of the allegations, a staff accused of abuse or neglect could be removed from the schedule immediately.

On 09/20/21 at approximately 1330 during an interview, the Recipient Rights Officer (RR H) indicated they did not remove accused staff from the provision of direct patient care during an abuse/neglect investigation. RR H indicated that was the responsibility of clinical leadership and human resources staff. RR H indicated they made recommendations to clinical leadership once the abuse/neglect investigation was completed. RR H indicated abuse/neglect investigations usually averaged 5 days to complete, and depending on the circumstances, the investigation could take much longer.

On 09/20/21 at approximately 1440, a review of facility policies and procedures pertaining to abuse and neglect was completed. Policies and procedures reviewed including those titled, "Abuse And Neglect" last revised on 02/10/21, and Human Resources policy titled, "Patient Abuse and Neglect" effective 09/01/15.

The policy titled, "Abuse And Neglect" last revised 02/10/21 indicated, under procedures section A, "3. All complaints involving abuse or neglect shall be forwarded to StoneCrest Center's Office of Recipient Rights for investigation ...", and under procedures section B, 4. Clinical Administrator "b. Takes appropriate action as necessary to ensure safety of the recipient alleging abuse or neglect; this may include suspending an accused employee pending the investigation.", and 5. Recipient Rights Officer, "a. Investigates the alleged abuse/neglect complaint and makes recommendations to the CEO/designee.", and 6. Chief Executive Officer, "3. If allegation of abuse or neglect is substantiated by the Rights Office, ensure remedial action is taken", and "Depending on the severity of the abuse or neglect substantiation, one of the following actions will be taken: Official reprimand, Reassignment, Demotion, Suspension, Termination".

The Human Resources policy titled, "Patient Abuse and Neglect" effective 09/01/15 indicated, under procedure section, "Any staff connected to any allegation of patient abuse, whether witnessed or alleged, will be immediately removed from the schedule and placed on suspension pending the outcome of the investigation.".

These policies as written and implemented did not protect the patient or other patients from abuse when an alleged perpetrator was allowed to continue to work in the hospital, having access to other patients, while the full investigation was not complete.