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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 all patients. Findings include:

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A-0145 Failure ensure that patients are free from all forms of abuse, neglect, or harassment; failure to have policy in place to protect patients from an alleged abuser.

Based on interview and document review, the facility failed to ensure patients are free from all forms of abuse, neglect and harassment for 1 (#1) of 1 patients and failed to develop and implement policies to protect patients from an alleged abuser resulting in the potential for unsatisfactory patient outcomes for all patients served by the facility. Findings include:

Review of the medical record on 11/3/2021 at 1105 revealed Patient #1 was an 82-year-old female with a past medical history of dementia, degenerative joint disease, osteoporosis (bones becoming weak and brittle), tobacco addiction, gastroesophageal reflux disease (GERD-heartburn), degenerative disc disease of the lumbar spine, postherpetic neuralgia (pain in nerve fibers generally associated with shingles), stress incontinence (leaking of urine brought on by a stressor such as a cough or sneeze), and depression with anxiety.

Patient #1 had been brought to the emergency department (ED) on 9/11/2021 following an alleged assault by her son for a psychiatric evaluation as her family members had stated she was hallucinating and violent toward them. The EMS (emergency medical services) note dated 9/11/2021 stated Patient #1 was "sitting in the car calm, alert ...Daughter is yelling and hysterical on scene. Pt (patient) is refusing to get out of the car. Per family she is violent and hallucinating ...She said her son grabbed her arm and hurt it, so she hit him ...agreed to go to the hospital for a (psychiatric) evaluation." The admitting history and physical exam (H&P) dated 9/11/2021 at 1203 indicated Patient #1 lived at home with her son and daughter.

Case management documented on 9/12/2021 at 1630, "All information obtained from the medical record due to pt's current mental status. Pt resides with her son and daughter. On previous admission pt accused son of domestic abuse. APS (adult protective services) case was open at that time and APS had been out to the house multiple times for domestic incidents. This admission daughter states that the patient was hallucinating and pt's son grabbed her arm. The patient became aggressive with her son stating that he bruised her arm. Social work consult for Possible abuse/neglect/elder abuse."

A physical therapy note dated 9/12/2021 at 0927 stated, "She indicates that her son and daughter are 'mean' and shows a bruise on her left arm reporting 'someone tried to pull me out of a car, it was my daughter.'"

A "Spiritual Care Assessment" documented 9/13/2021 at 0715 stated, "She appeared confused as she stated she did not know why she is here or who is in charge. She said she was afraid. She also told me that her children are violent and abuse her. She told me she got the bruise on her left forearm from being pulled from her car when her child wanted to drive it after she said, 'no.'"

Social Worker Staff Z documented on 9/13/2021 at 1015 that she had received a consult for possible abuse/neglect. She wrote, "Chart reviewed. It appears patient has poor family dynamics and (history) of abuse complaints. Previous hospitalization in 11/2020 was for a hip fracture where patient reported an altercation with her daughter ...Pt's story remains the same during this admission... Pt reports that her daughter is the one that is aggressive. Per patient, she is afraid of her daughter... reports her daughter is just a brat and stated she is safe to go home and is not afraid to return back home... After speaking with patient, it appears that the entire family has poor family dynamics. Per chart review, previous APS (adult protective services) report was made ..." Staff Z contacted APS with questions regarding the previous report and was told the report had been closed in 4/2021 and "were under the impression that the patient's children were no longer residing with her." When Staff Z informed APS that the children were still living with Patient #1 in her home, Staff Z was instructed for file a new APS report.

A psychiatric consult was conducted on 9/13/2021 by Psychiatric Physician Staff CC. The evaluation concluded Patient #2 had acute encephalopathy and "major neurocognitive disorder, most likely of the Alzheimer's type." In the recommendations section of the consult, Staff CC wrote, "I do believe we have acute encephalopathy, most likely from the UTI (urinary tract infection), superimposed on pre-existing dementia ...APS is already involved regarding her allegations of abuse. That needs to be assessed before discharging her home to her children." In a psychiatric follow-up note dated 9/15/2021, Staff CC stated, "" ...does not respond very well with medication, other than very temporary calming effect ...Redirection will only work for so long, sometimes just a few minutes. She needs to be in a safe environment, (either) with her family who can supervise her around-the-clock, or in the memory care unit. She is not competent to making any decisions any longer ..."

On 11/4/2021 at 0856, Staff CC stated the patient had dementia and was "very agitated and confused. She wanted to go home." He admitted much of the H&P had been obtained through family members. He stated it was not uncommon for dementia patients to claim family members were abusing them; however, upon questioning, admitted that claims of abuse by a dementia patient should not be discounted.

On 11/4/2021 at 1501, the Manager of Outcomes (Case Management) Staff AA stated Case Manager Staff RR had called and explained Patient #1 had been "cleared by psych" to return home. She stated in a case where the patient has dementia, is deemed incompetent, and the family was the abuser, that the patient would not be sent home, and APS would be notified. Staff AA stated the hospital was able to gain emergency guardianship in certain cases and did so at considerable cost to the facility. She confirmed that no emergency guardianship by the facility had been obtained or was in the process of being obtained. She stated she didn't know, and was not sure if her staff were aware that APS was trying to obtain emergency guardianship for the patient. Staff AA was then asked for policies regarding emergency guardianship and for how staff should proceed with abuse cases and/or APS referral. Staff AA stated it was common knowledge on how to proceed and she did not think there were any policies for those that were requested. Staff RR was unavailable for interview as she was off on medical leave.

Patient #1's hospital course described in the discharge summary dated 9/15/2021 stated, "...The patient has baseline dementia. She is living with her son and daughter. She accused her son (of) grabbing her left arm and causing a bruise. She had previous problems with her kids but also (does not) want to leave the home as she needs care... Psychiatry was consulted as well as social services for elderly care/abuse evaluation... Due to the bruising on the left forearm (an) x-ray was done which did not show any fracture... She was then (discharged) home as no abuse found."

Patient #1 was discharged home in the care of her daughter on 9/15/2021 at 1524.

Review of the Complaints and Grievance Log from 8/1/2021-11/2/2021 revealed no other complaints of abuse were present. This finding was confirmed by Staff QQ on 11/2/2021 at 1536.

Review of the Incident Reporting Log from 8/1/2021-11/2/2021 revealed no incidents of abuse found to be present. This finding was confirmed by Staff QQ on 11/2/2021 at 1536.

On 11/4/2021 at 0910, review of facility policy titled "Adult/Elder Abuse Neglect", undated, revealed the following: "... Adult/Elder Abuse is any harm or threatened harm to an adult's health or welfare caused by another person. This includes non-accidental physical injury, mental injury, sexual abuse, or maltreatment...If in the process of medical examination an adult is determined to be vulnerable (not able to make informed decisions regarding care) and adult/elder abuse, neglect or exploitation is determined, the physician, resident, or nurse will immediately contact the social worker... The social worker will review the case and talk with the patient, then make the necessary phone call to Centralized Intake/Adult Protective Services if the patient lives in their own home or with family... The social worker will coordinate the assessment for the potential protective services referral with the attending physician, resident, and/or nursing personnel prior to implementing the phone call to Centralized Intake... when the hospital staff have reason to know or suspect that an adult is being abused or neglected (which maybe on the basis of the statements from the patient), the hospital social worker will coordinate the referral to Adult Protective Services." The policy does not address how or when emergency guardianship should be obtained.

2) During the review of facility policy titled "Allegation of Patient Abuse/Neglect" effective 1/6/2021, it was noted there was a lack of policy/procedure on what should occur if a hospital employee/contracted employee was accused of assault of any type including removal of the alleged perpetrator from all patient care until the investigation was complete.

On 11/4/2021 at 0921, Staff QQ was queried as to what steps were taken if a hospital or contracted employee was identified as an alleged abuser to which she stated, "The staff member would be removed immediately and placed on paid leave until the investigation was completed. We work with (human resources) on that." When queried as to if there was another policy that addressed what she had just described, Staff QQ shook her head and stated, "No. This would be it."

Based on interview and record review, the facility failed to ensure effective discharge planning and coordination of care for 1 (#1) of 1 patients who alleged abuse resulting in the potential for harm up to and including death for all patients who allege abuse that are served by the facility. Findings include:

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A-800 Failure to ensure an adequate and effective discharge plan

Based on interview and record review, the facility failed to ensure adequate discharge planning for 1 (#1) of 1 patients alleging abuse resulting in the potential for harm, up to and including death, for all patients alleging abuse that are served by the facility. Findings include:

On 11/3/2021 at 1105, review of the medical record for Patient #1 revealed she was an 82-year old female who was brought to the emergency department (ED) via ambulance on 9/11/2021 with a past medical history of dementia, degenerative joint disease, osteoporosis (bones becoming weak and brittle), tobacco addiction, gastroesophageal reflux disease (GERD-heartburn), degenerative disc disease of the lumbar spine, postherpetic neuralgia (pain in nerve fibers generally associated with shingles), stress incontinence (leaking of urine brought on by a stressor such as a cough or sneeze), and depression with anxiety. A large contusion was noted on her left wrist/lower forearm area.

Review of the EMS (emergency medical services) run sheet dated 9/11/2021 revealed documentation in the area for injury "Assault-Assault with bodily force-Home-9/11/2021... She said her son grabbed her arm and hurt it, so she hit him ...agreed to go to the hospital for a (psychiatric) evaluation."

Further review of the medical record revealed Patient #1 was admitted with acute metabolic encephalopathy and UTI (urinary tract infection). When interviewed on 11/3/2021 at 1342, ED Physician Staff W stated, "She reported aggression with her family... Normally I would have considered contacting family for outpatient oral antibiotics, but chose to admit because of what she said and because of the EMS report. It gave the social worker time to look." Staff W ordered a psychiatric consult on 9/11/2021 at 2033. The reason for the consult stated, "possible mild dementia and elderly abuse as well." Patient #1 also told various staff members during her hospitalization of abuse at home. A physical therapy note dated 9/12/2021 stated, "She indicates that her son and daughter are 'mean' and shows a bruise on her left arm reporting 'someone tried to pull me out of a car, it was my daughter.'" Pastoral care documented 9/13/2021, "She also told me that her children are violent and abuse her. She told me she got the bruise on her left forearm from being pulled from her car when her child wanted to drive it after she said, 'no.'"

The initial care management assessment dated 9/12/2021 stated Patient #1 resided with her son and daughter. Multiple attempts to contact both the son and daughter were unsuccessful so past medical records had to be used to obtain information. The record stated, "On previous admission pt accused son of domestic abuse. APS (adult protective services) case was open at that time and APS had been out to the house multiple times for domestic incidents. This admission daughter states that the patient was hallucinating and pt's son grabbed her arm. The patient became aggressive with her son stating that he bruised her arm. EMS report with additional details. Social work consult for Possible abuse/neglect/elder abuse."

A psychiatric consult was conducted on 9/13/2021 by Psychiatric Physician Staff CC. The evaluation concluded Patient #1 had acute encephalopathy and "major neurocognitive disorder, most likely of the Alzheimer's type... I do believe we have acute encephalopathy, most likely from the UTI, superimposed on pre-existing dementia ...APS is already involved regarding her allegations of abuse. That needs to be assessed before discharging her home to her children."

Social Worker Staff Z documented on 9/13/2021 that she had received a consult for possible abuse/neglect. She wrote, "Chart reviewed. It appears patient has poor family dynamics and (history) of abuse complaints. Previous hospitalization in 11/2020 was for a hip fracture where patient reported an altercation with her daughter ...Pt's story remains the same during this admission ...Per chart review, previous APS report was made ..." Staff Z contacted APS with questions regarding the previous report and was told the report had been closed in 4/2021 and "were under the impression that the patient's children were no longer residing with her." When Staff Z informed APS that the children were still living with Patient #1 in her home, Staff Z was instructed for file a new APS report. A new report was filed and Staff Z "requested call back from assigned worker and expressed the urgency of a visit within 24-48 hours of discharge. Anticipated (discharge pending)-Home with APS report and urgent APS follow-up."

Later in the day on 9/13/2021, Staff Z conducted a social work evaluation at the patient's bedside and documented the patient lived with her daughter and son. Patient #1 did not have a durable power of attorney. She wrote, "Pt adamant on returning home at (discharge) ...(discharge pending)-Home with APS report."

Further review of the medical record revealed Psychiatric Physician Staff CC saw Patient #1 for a second time on 9/15/2021. The documentation stated " ...She needs to be in a safe environment, (either) with her family who can supervise her around-the-clock, or in the memory care unit. She is not competent to making any decisions any longer ..."

When interviewed on 11/4/2021 at 0856, Physician Staff CC stated Patient #1 had "dementia with increased confusion because of the UTI. She was very agitated and confused ...Much of the information I received was from the family and from the (nurse practitioner)." He stated he did look at past medical encounters and saw that she had made other allegations of abuse from her family. Staff CC stated it was very common for demented patients to claim their family members are abusing them; however, did admit upon questioning that the claims of abuse cannot be discounted just because the patient has dementia. "It was my opinion that the patient needed to be watched 24/7 whether with family or in memory care ...There was no reason to suspect the daughter was beating her up."

During an interview with Staff Z on 11/3/2021 at 1427, she stated she "expressed concern for an urgent response in 24-48 hours." When queried as to the response from APS, she stated she was talking with a dispatcher and the dispatcher said, "Okay. We will follow up." Staff Z stated it was common practice with cases of suspected abuse to have talks back and forth with APS during the patient's hospitalization. Staff Z admitted she was aware of Patient #1's confusion and dementia diagnosis and she was aware of the potential abuse. She also stated she was aware that a psychiatric consult had been completed but did not see the documentation prior to the patient's discharge. Staff Z further stated she discussed Patient #1's case with her manager, Staff AA, as either the physician or the manager clears the patient for discharge. "I was told by management it was okay to send the patient home with family even if she was deemed incompetent." When queried as to if it were okay to send the patient home with family when the family she was discharged to were her abusers, Staff Z did not comment, but shrugged her shoulders and shook her head portraying she did not know the answer.

The Manager of Outcomes (Case Management) Staff AA stated during interview on 11/3/2021 at 1501 Case Manager Staff RR had called and explained Patient #1 had been "cleared by psych" to return home. She stated in a case where the patient has dementia, is deemed incompetent, and the family was the alleged abuser, that the patient would not be sent home, and APS would be notified. Staff AA confirmed that no emergency guardianship by the hospital had been obtained or was in the process of being obtained. She stated she didn't know if her staff were aware that APS was trying to obtain emergency guardianship for the patient.

On 9/13/2021, Case Manager Staff RR documented a discharge plan of returning home with the support of her children. It was noted that social work was following up with APS. Transport home via son/daughter. Anticipated discharge was in 24-48 hours. The discharge plan submitted by Staff RR on 9/14/2021 was the same except the note regarding social work had changed to state, "filed with APS." Case Manager Staff RR was unavailable for interview as she was off on medical leave.

Patient #1 was discharged home with her daughter on 9/15/2021 at 1524. The discharge summary stated, " ...She accused her son grabbing her left arm and causing a bruise. She had previous problems with her kids but also (did) not want to leave the home as she needs care ...Psychiatry was consulted as well as social services for elderly care/abuse evaluation ...Due to the bruising on the left forearm x-ray was done which did not show any fracture ...CT (computerized tomography-CT scan) head was ordered it was (negative). She was then (discharged) home as no abuse found."

On 11/4/2021 at 0910, review of facility policy titled "Adult/Elder Abuse Neglect", undated, revealed the following: "... Adult/Elder Abuse is any harm or threatened harm to an adult's health or welfare caused by another person. This includes non-accidental physical injury, mental injury, sexual abuse, or maltreatment...If in the process of medical examination an adult is determined to be vulnerable (not able to make informed decisions regarding care) and adult/elder abuse, neglect or exploitation is determined, the physician, resident, or nurse will immediately contact the social worker... The social worker will review the case and talk with the patient, then make the necessary phone call to Centralized Intake/Adult Protective Services if the patient lives in their own home or with family... The social worker will coordinate the assessment for the potential protective services referral with the attending physician, resident, and/or nursing personnel prior to implementing the phone call to Centralized Intake... when the hospital staff have reason to know or suspect that an adult is being abused or neglected (which maybe on the basis of the statements from the patient), the hospital social worker will coordinate the referral to Adult Protective Services." The policy does not address how to ensure patient safety via emergency guardianship or any other means following the referral to APS.