HospitalInspections.org

Based on record review, policy review, and interview, the Hospital failed to protect patients from potential abuse during the investigation of an alleged incident of abuse and failed to ensure appropriate corrective action occurred following the investigation of the alleged abuse for 1 of 5 patients (Patient 1). This deficient practice has the potential to place patient at risk for harm or other adverse outcomes.

Findings Include:

Review of Hospital's policy titled, "Prevention and Protection of Patient Abuse, Neglect or Harassment" revised on 10/2010 showed, "Policy Statement: Olathe Medical Center has mechanism/methods in place to prevent or protect patients from all forms of abuse, neglect, or harassment ..." " ...Definitions: Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This includes staff neglect or indifference to infliction of injury or intimidation of one patient by another ..."

" ...Procedure: ...Protect: ...protect patients from abuse during investigation of any allegations of abuse neglect, or harassment


Patient 1

Review of Patient 1's medical record showed Patient 1 was admitted on 05/20/23 with a chief complaint of black tarry stools (melena) on 05/19/23 and 05/20/23. Patient 1 had low back pain that she experienced when she had Gastrointestinal (GI) bleed. Patient 1 had a deep cough and required supplemental home oxygen (O2). Patient 1 had a medical history of weakness; fatigue; lightheadedness, Dyspnea (short of breath) on exertion with symptom onset two weeks previously.

Review of Patient 1's "Physician Orders" showed that Patient 1 had an order for nothing by mouth (NPO) on 05/20/23 at 3:46 PM, "No exceptions."


On 05/21/23 at 12:45 PM, Patient 1 had a Gastroenterologist (GI) consult for her anemia (low blood count). The GI physician offered Patient 1 a clear liquid diet due to her right upper quadrant pain and black tarry stools. Patient 1 refused and became upset, and stated that she wanted to eat regular food or nothing at all. Patient 1 asked the GI doctor to leave the room.


Review of nursing documentation dated 05/21/23 at 3:03 PM by Staff H, RN showed "GI consult performed and personally spoke to [Staff J, GI MD] regarding plan of care. Request to continue Proton pump inhibitor (PPI - reduces the amount of stomach acid in the lining of the stomach) drip and patient refused. Will contact [Staff N, MD] in request to increase pain medications. Patient requesting scheduled Clonazepam only. [Staff N] stated, "Patient needs to fully comply with all of GI recommendations, if any are refused by the patient, the patient needs to be discharged."


Review of a document title "Patient Complaints/Grievance Event" dated 05/22/23 at 5:52 PM showed the date of the event occurred on 05/21/23 at 2:37 PM, Patient 1 requested a visit from the patient advocate. Patient 1 reported that the RN got right in her face and yelled at her that if she didn't take the Protonix then she was going take away Patient 1's pain medication and other medications. [Staff H, RN] called the physician regarding pain medication but did not clarify with the physician regarding other pills (Klonopin)... [Staff Q, RN, Case Manager (RNCM)] and [Staff I, RN, Unit Coordinator] talked with Patient 1 and Patient 1 was very upset and stated, "I am being forced to leave the hospital because I would not take the Protonix."


During an interview on 06/19/23 at 11:16 AM, Staff P, RN stated that Patient 1 said that she was scared of her nurse, and that the nurse had been yelling at her all day.


During an interview on 06/16/23 at 1:39 PM, Staff I, Registered Nurse (RN) Coordinator stated, "I am not sure if the Staff H, RN was talked with regarding allegations but just removed from patient care."


During an interview on 06/19/23 at 12:29 PM, with Staff N, MD stated that she told the nurse to tell Patient 1 "If you don't want to do the prescribed treatment, then you can discharge." Staff N stated that of course they will try to incorporate important medications with a sip of water once we know that there will not be a test that day.


During an interview on 06/19/23 at 10:53 AM Staff T, RN supervisor stated that Staff H was reassigned to a different patient, but she was not removed from 2 north unit and was able to continue providing patient care to other patients.


Staff H, RN, was removed from caring for Patient 1, however Staff H, continued to care for other patients following the allegation abuse.