HospitalInspections.org

Based on document reviews, medical record reviews, and staff interviews, it was determined that the facility failed to immediately initiate an investigation into reports of potential patient abuse or neglect upon learning of patient bruising (see tag A0145). This failure has the potential to negatively impact all patients receiving care at the facility.

Based on document reviews, medical record reviews and staff interviews, it was determined that the facility failed to immediately initiate an investigation into reports of potential patient abuse or neglect upon learning of patient bruising after receiving a phone call questioning a patient's skin condition, in one (1) out of one (1) patients discharged to Hospice, patient #1. This failure has the potential to negatively impact all patients receiving care.

Finding include:

A review of facility policy, titled "Abuse and/or Neglect (Alleged or Suspected)", last revised 07/11/22, states in pertinent part: "Policy: ... To the best of our ability will protect patients from real or perceived abuse, neglect or exploitation from anyone including staff, students and volunteers, other patients, visitors or family members. The hospital will internally investigate all allegations, observations or suspected cases of abuse, neglect or exploitation that occur in the hospital."

A medical record review was conducted for patient #1. The patient presented to the facility Emergency Department (ED) via Emergency Medical Services (EMS) on 05/14/23 at 8:35 a.m. with a chief complaint of weakness, diarrhea, and dizziness. A "ED Primary Provider Note" at 8:35 a.m. states in part, "...Physical Exam ...Skin: Skin is warm and dry. extensive fungal rash across lower abdomen, inguinal and genital area as well as underneath the breast..." A Foley Catheter was inserted at 10:30 a.m. for accurate urine output measurements. The patient was diagnosed with acute renal failure and admitted to the fifth (5th) floor medical/surgical unit. The patient had a previously appointed Medical Power of Attorney (MPOA), and was noted to be confused. On 05/16/23 at 11:46 a.m., wound care was consulted for bilateral lower leg discoloration. Pictures were taken and added to the medical record. On 05/16/23 at 12:14 p.m. On 05/22/23 at 11:15 a.m., a Palliative Care was consulted for an evaluation. The evaluation states in part, "...The family has been noting an ongoing decline in mentation and function over the past few weeks months. The family is realistic. The [MPOA] acknowledges that the patient may potentially suffer with ongoing decline and repeat hospitalizations. The patient is wanting us to continue to treat [patient #1] with the goal of rehab placement. The [MPOA] agrees for ongoing treatment and Rehab placement but [MPOA] is unsure of how much benefit [patient #1] will gain from rehab. If the patient's condition deteriorates further, the [MPOA] would like to consider hospice care..." Family inclined toward hospice after having a meeting. Patient will be discharged to hospice facility." "Nurse Note" on 05/24/23 at 3:04 p.m. by RN #2 states, "Patient's [MPOA] updated that transport left with patient for hospice. All IVs and Foley cath [catheter] left in per hospice request. No belongings left in patient ' s room."

An interview was conducted with RN #2 on 06/14/23 at 2:49 p.m. Regarding patient #1, RN #2 states in part, "The hospice called right after [patient #1] got there ...They asked did [patient #1] have bruising on [patient #1] thighs and vaginal area. I said no, and I don't do an assessment inside the vagina. I did Foley care and didn't see anything. That's what I told them. I questioned if it could be blood pooling since [patient #1] had been setting up for at least twelve (12) hours due to [patient #1] difficulty breathing ...I did mention the call to the charge nurse. We had a discussion about it and we were confused about the bruising on the thighs. We couldn't figure out what it could be. The hospice just asked if the bruises were present before the patient left. [Hospice nurse] didn't say anything else. I didn't put in an incident report because it wasn't an incident that actually occurred, it was just a phone call. I didn't know you could put an incident report in for a phone call."

A telephone interview was conducted with Hospice RN #1 on 06/15/23 at 9:54 a.m. Regarding patient #1, Hospice RN #1 states in part, "The patient's entire peri-area was purple. The top of the super pubic area was all purple, and the upper thighs were. The bruising was symmetrical, and it was in the high upper thigh, near the vaginal area ...I did call the hospital [on 05/24/23, evening, unknown time] and spoke with the floor nurse. I only asked if [RN #2] had seen any bruising in that area and [RN #2] said no. It would have been obviously seen by any nurse doing peri-care. [Patient #1] skin did not bruise or discolor when we lifted [patient #1], or where we would have held [patient #1] or transferred [patient #1]. This is my first time seeing something like this. I filled out the APS form with the social worker's help."

An interview was conducted with the Nurse Manager (NM) of unit 5F (Five Front) on 06/14/23 at 2:02 p.m. Regarding patient #1, after the NM was made aware of the potential abuse on 06/01/23 from the patient advocate, the NM states, "I looked at all the documentation in the medical record. I looked at the Staffing for about four (4) days prior to the patient's discharge. I talked with the night nurses, the day nurses, the techs [Patient Care Technicians (PCT)] and the charge nurses. No one saw any suspicious bruising. Most of them said there was no bruising in that area. There was just bruising on the arms and abdomen from Heparin shots. The hospice had called [RN #2] and asked if the patient had any bruising that [RN #2] knew of and [RN #2] said no. [RN #2] and the tech [PCT] had cleaned [patient #1] up before [patient #1] left. They both noted they didn't see any bruising. I didn't ask [RN #2] why [RN #2] didn't fill out an incident report- I didn't know [RN #2] had to. The hospice didn't relay any information on suspecting rape. The patient had mottling and [patient #1] was sitting up a lot due to difficulty breathing. [Patient #1] also had low platelets and was more apt to bruising. I assumed the bruising in that area was caused by the way [patient #1] was sitting and blood pooling."

An interview was conducted with the patient advocate on 06/14/23 at 1:33 p.m. Regarding patient #1, the patient advocate states, "APS [Adult Protective Services] called us on June 1st. APS said that there were pictures of the bruising. [APS worker] told me to make sure that you put in the report that there was dark purple bruising and [APS] said that meant they were fresh bruises. I immediately notified [Regulatory Compliance Coordinator (RCC)] and the legal team. APS said that they were calling the police and OHFLAC on that day. It hadn't been reported to anyone prior to this. The hospice had called and spoken to the nurse, but they didn't state any allegations of abuse, so nothing was reported. I'm currently in the process of training staff to use incident reporting for anything abnormal such as a phone call with questions from another facility. I immediately entered it as an incident report. We had a group meeting with the Patient Advocates, [RCC] and [Chief Nursing Officer (CNO)]. We looked at medical records and interviewed staff members.

A review was conducted of the facility ' s investigation into the potential abuse. The facility received a phone call from an Adult Protective Services (APS) worker on 06/01/23 at 2:32 p.m. of the alleged incident and was informed APS would be "reporting this to OHFLAC (Office of Health Facility Licensure and Certification) for immediate endangerment and ask them to come out and investigate." The facility did an extensive medical record review, and interviewed staff involved in the care of the patient. The Chief Nursing officer (CNO) also did a review. No evidence could be found of abuse. The facility closed the grievance as resolved on 01/06/23.

May it be noted, There is no evidence that the facility initiated an investigation into potential patient abuse or neglect, after learning of patient bruising on 05/24/23. The facility initiated an investigation after a telephone report from APS was received on 06/01/23.