HospitalInspections.org

Based on document review and interview it was determined that the Hospital failed to protect and promote patients rights by failing to follow abuse policy and an investigation of an alleged physical abuse. As a result, the Condition of Participation, 42 CFR 483.13 Patient Rights was not in compliance.

Findings include

1. The Hospital failed to ensure that patients were free from all forms of abuse, by not following the process for recognition and investigation of an allegation of abuse. See A-145.

A. Based on document review and interview, it was determined that for 1 of 2 patients' (Pt. #1) clinical records reviewed regarding allegations of abuse, the Hospital failed to ensure patients were free from abuse by failing to follow the process for recognition and investigation of an allegation of abuse.

Findings include:

1. On 9/7/2022, Pt. #1's clinical record was reviewed. Pt. #1 was admitted to the Hospital's behavioral health unit on 9/3/2022 with a diagnosis of severe bipolar disorder (a mental disorder with episodes of mood swings). Pt. #1 was discharged on 9/6/2022 at 2:47 PM. E #8's (Registered Nurse) progress notes on 9/6/2022 at 11:15 AM indicated, "(Pt. #1) was received in the room ... (complained of) being assaulted yesterday (9/5/2022) stating, 'I was assaulted, and nobody did anything about it' ... (E#7, Director of Behavioral Health Unit) was made aware of the situation ..."

2. On 9/7/2022, the Hospital's policy titled, "Adult Abuse Neglect and Domestic Violence Recognition and Reporting" (dated 12/21/2021) included, " ... Definitions: A. Abuse: Intentional maltreatment of an individual that may cause injury, either physical or psychological ... Procedure: 1 ... a ... The nurse or Administrative Supervisor will conduct an investigation and report the abuse ... to the proper agencies ... b ... 2 ... If abuse is suspected to have occurred in the Hospital, by hospital staff or others, the Administrative Supervisor, the Risk Manager and Unit Director needs to be notified immediately to begin investigation and an unusual occurrence report needs to be completed ..."

3. On 9/7/2022, Director of Behavioral Health (E #7's) incident report, dated 9/7/2022 at 12:58 PM included, "I was made aware this morning (9/7/2022) that a patient (Pt. #1) complained of being assaulted 2 days ago ... Will look into the matter."

4. On 9/7/2022 at approximately 2:25 PM, an interview was conducted with E #7 (Director of Behavioral Health Unit). E #7 denied receiving a report from E #8 regarding Pt. #1's allegation of being assaulted by staff. E #7 said, "I just heard about it when you guys came in today." E #7 stated that she had not started an investigation regarding Pt. #1's allegation of abuse by staff. (Approximately two days since Pt. #1 made an allegation).

5. On 9/8/2022 at approximately 9:05 AM, an interview was conducted with E #2 (Mental Health Specialist). E #2 stated, "That day (9/5/2022), (Pt. #1) was telling everybody (including the charge nurse/E #9) that I took a swing on him (Pt. #1)."

6. On 9/8/2022 at approximately 9:45 AM, an interview was conducted with E #8 (Registered Nurse). E #8 said, "As far as I know, there was no investigation regarding (Pt. #1's) allegation of abuse by the staff. I was supposed to write an incident report, but I forgot."


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B. Based on document review and interview, it was determined that for 1 of 2 (Pt. #1) clinical records reviewed for allegations of abuse, the Hospital failed to ensure that patients were free from all forms of abuse, by not removing staff from duty, during an ongoing investigation of alleged abuse.

Findings include:

1. On 9/7/2022, Pt. #1's clinical record was reviewed. Pt. #1 was admitted to the Hospital on 9/3/2022 with a diagnosis of severe bipolar disorder (a mental disorder with episodes of mood swings). Pt. #1 was discharged on 9/6/2022. E #8's (Registered Nurse) progress notes on 9/6/2022 at 11:15 AM indicated, "(Pt. #1) was received in the room ... (complained of) being assaulted yesterday (9/5/2022) stating, 'I was assaulted, and nobody did anything about it' ... (E#7, Director of Behavioral Health Unit) was made aware of the situation ..."

2. On 09/07/2022, the Hospital's policy titled, "Adult Abuse Neglect and Domestic Violence Recognition and Reporting" (dated 12/21/2021) included, " ... Definitions: A. Abuse: Intentional maltreatment of an individual that may cause injury, either physical or psychological ... Procedure: 1 ... a ... The nurse or Administrative Supervisor will conduct an investigation and report the abuse ... to the proper agencies ... b ... 2 ... If abuse is suspected to have occurred in the Hospital, by hospital staff or others, the Administrative Supervisor, the Risk Manager and Unit Director needs to be notified immediately to begin investigation and an unusual occurrence report needs to be completed ..." The Hospital's policy lacked the information regarding suspension of alleged perpertrator until inverstigation is completed and immediate assessment of patient upon allegation of abuse.

3. On 09/07/2022, Director of Behavioral Health (E #7's) incident report on 9/7/2022 at 12:58 PM included, "I was made aware this morning (9/7/2022) that a patient (Pt. #1) complained of being assaulted 2 days ago ... Will look into the matter."

4. On 09/08/2022 at 12:30 PM, the Hospital's Mental Health Specialist ( E #2) staff Schedule dated 09/04/2022 - 09/07/2022 was reviewed and included, "[Name of Staff - E #2] work schedule as follows: 09/04/2022 - 11:01 PM - 7:23 AM; 09/05/2022 - 11:03 PM - 7:36 PM; 09/07/2022 - 10:58 PM - 7:25 AM." In summary, E #2's work schedule indicated staff was working in the Hospital on 09/04/2022 and continued to work while the investigation was in progress until 09/07/2022.

5. On 09/08/2022 at 1:00 PM, the Chief Transformation Officer (MD #2) and Director of Behavior Health Unit (E #7) were interviewed. E #7 stated that the alleged perpetrator should have been suspended pending investigation. MD #2 stated that he realizes that it is not mentioned in the Hospital's policy to suspend an alleged perpertrator upon allegation of abuse. E #7 stated that they should have notified the nursing supervisor and an assessment of the patient (Pt. #1) should have been done.