HospitalInspections.org

Based on facility policy review, medical record review, review of facility documentation, review of facility communication, and interviews the facility failed to ensure a patient was free from abuse and failed to follow facility policy's related to abuse for 1 patient (Patient #4) of 2 patients reviewed for abuse of 10 patients reviewed.

The findings include:

Patient #4 was admitted to the Inpatient Rehabilitation Center (IRC) on 5/9/2023, after a hospitalization for COVID and Hypoxia. The patient had a past medical history of Congestive Heart Failure, Atrial Fibrillation, Type 2 Diabetes Mellitus, Hypertension, and Chronic Obstructive Pulmonary Disease. The patient was weak, but mainly in his legs. Patient #4 required moderate assistance with Activities of Daily Living and was totally dependent on staff for walking. On 5/16/2023, 2 Certified Nursing Assistants (CNA) were assisting the patient to transfer from a wheelchair to his bed, the patient's legs became weak, and he fell across the bed. Other IRC staff, including Registered Nurse (RN) #1, the alleged perpetrator (AP) went to assist with getting the patient in the bed. 5 IRC staff members heard RN #1 call Patient #4 derogatory names, telling him to shut up, and telling him he was lying about not being able to walk. RN #1 was observed pulling at the patient's shoulders and shirt collar when she was trying to move the patient up in the bed. Patient #4 was heard saying he could not breathe. RN #1 went back to Patient #4's room to apologize to the patient. Patient #4's nurse (Licensed Practical Nurse #1) reported the incident to the IRC nursing director the evening of 5/16/2023. An IRC employee reported the incident in the facility's incident reporting system on 5/17/2023 at 8:55 AM. The IRC Program Director was notified of the incident when she arrived to work on 5/17/2023. The Compliance Officer, CNO, and Risk Manager were notified by email that an incident had occurred at the IRC on 5/17/2023. The Risk Manager and IRC Program Director became aware of the allegation that RN #1 had been "...very ugly with a patient [Patient #4]...called him very bad names. yelled at him. told him to shut up. she was very disrespectful to him..." on 5/17/2023 . RN #1 worked 4 additional shifts (7:00 AM-7:00 PM) after the incident. The Program Director had spoken with and taken witness statements from 2 IRC staff members on 5/17/2023 , but the staff statements were not shared with anyone until 5/22/2023. The Chief Nursing Officer (CNO) and Assistant Chief Nursing Officer (ACNO) were not notified of the allegations of abuse until 5/22/2023. The ACNO further investigated on 5/22/2023. RN #1's employment was terminated on 5/25/2023. The facility failed to protect Patient #4 and other patients during an investigation for an allegation of abuse.

Refer to A-0145

Based on facility policy review, medical record review, review of facility documentation, review of facility communication, and interviews the facility failed to ensure 1 patient was free from abuse and failed to protect Inpatient Rehabilitation Center (IRC) patients during an investigation for an abuse allegation for 1 patient (Patient #4) of 2 patients reviewed for abuse of 10 patients reviewed.

The findings include:

Review of the facility's policy "Neglect and Abuse of Patients/Grievance Procedure" revised 8/2021, showed "...The [named program] will work to provide a safe and secure environment for its patients. It is the policy of the [named program] at the Rehabilitation Center at [named facility] to provide a system to support and respond to allegation should there be a breach in that safe environment. The following criteria will constitute neglect and abuse of patients by staff...Physical, verbal, or psychological abuse...Infringement on patient's rights and responsibilities...Should a patient feel that he/she or any family member or friend visiting the [named program] has been neglected or abused during the stay, he/she shall report this to a [named program] staff member who will in turn report the incident to the [named program] Program Director...The Program Director shall be responsible for reporting the incident to the appropriate hospital personnel and/or appropriate [named program] administrative staff...In all cases, the [named program] staff will follow all state laws regarding the appropriate reporting of abuse or neglect..."

Review of the facilities "Corrective Action Procedure" revised 1/2023, showed "...In order to achieve quality patient care and positive guest relations [named facility] has established and shall establish from time to time certain protocols and expectations of employee performance and behavior...when an employee has been unable or unwilling to comply with those protocols or meet those expectations, a four-step Corrective Action Procedure (CAP)...shall be initiated and administered. This CAP may be modified at any time, any step within the CAP may be eliminated, and other, alternative corrective action may be imposed if warranted by the nature and circumstances of the employee's performance or behavior issue...CORRECTIVE ACTION PROCEDURE Informal Action...managers and supervisors shall initially counsel an employee with performance or behavior issues...Generally a Corrective Action Procedure shall progress as follows: Step 1-Verbal Warning...Step 2-Written Corrective Action Step 3-Suspension Step 4-Discharge...Employee performance and behavior issues adversely impacting hospital operations or patient care will generally fall into one of the following categories...Conduct/Behavior Discourteous treatment of others...Lack of appropriate customer service behaviors...Abusive or discourteous language (includes foul language)..."

Review of the facility's policy "Compliance Investigation, Inquiry, and Discipline" revised 1/2023, showed "...This policy has been developed as part of [named facility] Compliance Program to outline the framework for investigating any reported potential violations of laws, regulations, or [named facility] compliance policies; and to ensure that individuals who violate these standards will be held accountable for their actions...Misconduct means any violation of governmental regulations or law, [named facility] compliance polices and standards (including the Code of Conduct), or any other practices that seriously deviate from those that are commonly accepted business practices...[named facility] is committed to maintaining integrity in all aspects of its business. All individuals affiliated with [name facility] (including but not limited to employees, managers, officers, trustees, contractors, and medical staff) are expected to act ethically and in accordance with applicable laws, regulations, and policies. Internal investigations may be conducted for a variety of reasons...[named facility] personnel found to have deliberately engaged in misconduct shall be disciplined in accordance with [named facility] policies and procedures...All allegations concerning possible instances of misconduct at [named facility] and/or by [named facility] personnel must be reported to the Compliance Officer...The Compliance Officer shall commence and/or oversee investigations on all compliance-related matters following receipt of the report indicating a matter warranting investigation...The investigation may include, but is not limited to...reviewing and preserving documents related to the matter...interviewing appropriate individuals...reviewing policies and procedures applicable to the matter...collaborating with members of [named facility] leadership, as needed...If a significant compliance violation is found, the Compliance Officer and/or department director or senior leader, shall develop and implement a corrective action plan...Corrective action may also include employee disciplinary action, in which case the Senior VP [Vice President] of Human Resources will be consulted...Employee suspension may occur when an investigation is indicated in order to learn all facts of a specific concern/allegation...Any employee may be immediately discharged for flagrant violations, such as (including, but not limited to...Criminal acts...Violations of any state, federal, local laws, regulations, or standards...Neglect/abuse of any patient..."

Review of the facility's "Employee Handbook" revised 1/2023, showed "...Workplace harassment is a form of offensive treatment or behavior, which to a reasonable person creates an intimidating, hostile or abusive work environment. It may be sexual, racial, based on national origin, age, disability, religion or a person's sexual orientation. It may also encompass other forms of hostile, intimidating, threatening, humiliating or violent behavior, which are not necessarily illegal discrimination but are nonetheless prohibited by this policy...It is misconduct for an employee to direct the subject behavior at another employee of whatever stature, or to customers, contractors or visitors to the work site...It is misconduct for managers or supervisor who know or should have known of workplace harassment to fail to report such behavior, or to fail to take immediate appropriate, corrective action...Disparaging or disrespectful comments even if unrelated to a person's race, color, sex, national origin, religion, age, disability or sexual orientation; or loud, angry outbursts or obscenities directed toward another employee, a customer, contractor or visitor in the workplace...Conduct for which corrective actions will be imposed includes, but is not limited to...Neglect or abuse of any patient...An employee may be immediately suspended or terminated for misconduct. Examples considered as justification for immediate suspension or termination include...Behavior detrimental to the welfare, safety, convenience, or comfort of patients, visitors, or employees..."

Medical record review of a history and physical showed Patient #4 was admitted to the facility's IRC on 5/9/2023, after a hospitalization for COVID and Hypoxia. The patient had a past medical history of Congestive Heart Failure (CHF), Atrial Fibrillation, Type 2 Diabetes Mellitus, Hypertension, Chronic Obstructive Pulmonary Disease (COPD), Gastroesophageal Reflux Disease (GERD), and Benign Prostatic Hypertrophy (BPH-non-cancer overgrowth of tissue). The patient felt "...diffusely weak but mostly in his legs..." Patient #4's level of function on admission to the Rehabilitation Center for rolling left and right, sitting to lying, lying to sitting on edge of bed, and sit to stand was 2 indicating the staff did more than half the effort to complete the activity; transfer to bed/chair and toilet transfer was unknown. The patient's ability to walk and use of stairs had not been assessed. Patient #4's rehabilitation barriers included "...at risk for worsening weakness, functional decline, risk for falls with subsequent injury due to weakness. Debility with decrease in functional mobility, gait [walking] impairment, risk for falls...immobility [not moving], impaired ADLs [activities of daily living]..." Patient #4's admission diagnoses included Chronic Hypoxic Hypercapnic Respiratory Failure , CHF, COPD, Debility, Decrease in Mobility, Decrease in Physical Functioning, Gait Impairment, Type 2 Diabetes with Peripheral Neuropathy (nerve problem that causes pain, numbness, tingling, swelling, or muscle weakness in different parts of the body), Anxiety/Depression, BPH, GERD, and Anemia (a problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues).

Medical record review of Physical Therapy (PT) progress notes for 5/16/2023 at 7:41 AM, showed Patient #4 required moderate assistance (helper lifts, holds, or supports the patient's trunk or arms) to go from a sitting to standing position and required supervision or touching assistance (provide verbal cues or touching/steadying assistance) when transferring from the chair to the bed. Patient #4 was totally dependent (patient provided no effort or required assistance of 2 or more people) to walk.

Review of a facility event report dated 5/17/2023 at 8:55 AM, showed Registered Nurse (RN) #1, alleged perpetrator (AP) had been "...very ugly with a patient [Patient #4]...called him very bad names. yelled at him. told him to shut up. she was very disrespectful to him..."

Review of facility communication regarding the incident involving RN #1 and Patient #4 showed the following:
*5/17/2023 at 11:29 AM: The IRC Program Director contacted the Compliance
Director and Chief Nursing Officer (CNO) stating the IRC staff reported an
incident with a patient that had occurred the prior evening (5/16/2023). The IRC
Nursing Director was on vacation, and she did not have access to the report. The
Program Director reported she had interviewed the patient (Patient #4) and staff
members who were present at the time of the incident.
*5/17/2023 at 11:32 AM: The Compliance Director responded to the IRC Program
Director and copied the CNO and Risk Manager. The Compliance Director
informed the IRC Program Director the Risk Manager would let her know what
the next steps were.
*5/17/2023 at 12:09 PM: The IRC Program Director provided the patient's name
and room number to the Risk Manager.
*5/17/2023 at 12:25 PM: The Risk Manager provided the IRC Program Director
with an electronic report that had been entered regarding an event involving
Patient #4 that occurred on 5/16/2023 at the IRC. The report showed that RN #1
had been disrespectful to Patient #4. The RN had yelled at the patient, called the
patient derogatory names and had told him to shut up.
*5/17/2023 at 12:45 PM: The IRC Program Director notified the Risk Manager the
staff were in tears when speaking with her about the incident. The Program
Director notified the Risk Manager she had written statements from 2 CNA's
who were in the room at the time of the incident.
*5/21/2023 at 5:19 PM: The IRC Program Director reached out the Risk Manager
and again, notified her she had written statements from 2 CNA's regarding the
incident. The patient's family had asked that RN #1 have no contact with the
patient. The charge nurse for 5/21/2023 was aware of the family's request.
*5/22/2023 at 7:04 AM: The Risk Manager provided the report regarding the
incident that occurred on 5/16/2023, to the CNO and Assistant CNO (ACNO).

Review of a facility event report dated 5/22/2023 at 10:34 AM , showed Patient #4 was being transferred from his wheelchair to the bed by 2 Certified Nurse Assistants (CNA) when the patient's legs became weak, and he tipped over onto the bed. Due to Patient #4's size, the CNAs were unable to assist the patient into the bed, so they called out for assistance. The charge nurse (RN #1 and AP) walked up behind the patient and put her right foot behind the patient's right foot and told him to move his foot up to which the patient stated he could not move his foot. RN #1 (AP) "...yelled at him to 'Move your foot up!'..." Patient #4 told RN #1 he could not move his foot. RN #1 responded "... 'You walk so you should be able to move your foot up...You're lying! I know you walk.'..." The reporting nurse told RN #1 the patient could not walk. Patient #4 began saying that he was having a hard time breathing and RN #1 yelled "...'SHUT THE [explicative] UP! You're talking so you're breathing'..." The reporting nurse tried to redirect RN #1 and de-escalate the situation. RN #1 then "...grabbed the pt [patient] by his shoulders and began trying to lift him up by his shoulders and t-shirt...pt face went red then purpleish [purplish] red..." The reporting nurse began screaming at RN #1 telling her to let the patient go and to let her get the gait belt [device used to support patient when walking or transferring]. RN #1 finally let go of the patient and he laid his head back down on the bed. The staff were able to get Patient #4 up in the bed using a gait belt. At some point, RN #1 called the patient a "...Fat [explicative]..." As RN #1 walked out of the patient's room she was heard saying "...'I hate him or I can't stand him'...when this nurse [reporting nurse] went back in the room 5 minutes later, pt was crying and kept apologizing and kept telling me to tell [RN #1] he was sorry..."

Review of RN #1's (AP) time clock punches showed RN #1 worked 7:00 AM-7:00 PM on 5/19/2023, 5/20/2023, 5/21/2023, and 5/22/2023 (4 shifts) after the incident occurred with Patient #4 on 5/16/2023.

During an interview on 6/5/2023 at 1:00 PM, in the conference room, the Risk Manager stated the event with RN #1 and Patient #4 occurred on 5/16/2023. On 5/17/2023, the IRC Program Director sent an email to the Risk Manager requesting access to the event reporting system because an event had occurred at the IRC, and she wanted to make sure it had been reported. The Risk Manager stated the email did not provide information about the incident. According to the Risk Manager, the IRC Program Director did an investigation after staff reported concerns of how Patient #4 had been spoken to by a staff member. The Risk Manager located the report and forwarded the information to the IRC Program Director . The Risk Manager received an email from the IRC Program Director on 5/21/2023 , indicating she obtained witness statements. The Risk Manager stated she was not aware of details of what had happened until the Program Director emailed her on 5/21/2023 informing her the IRC Program Director had obtained witness statements. The Risk Manager escalated the concerns to the CNO and ACNO on 5/22/2023.

During an interview on 6/5/2023 at 2:00 PM, in the conference room, the ACNO stated she was not aware of the incident that occurred with Patient #4 and RN #1 until 5/22/2023.

During an interview on 6/5/2023 at 2:20 PM, in the IRC conference room, the IRC Nursing Director stated he was notified by telephone that "...there had been words between a patient in room #23 [Patient #4] and a staff member..." the evening the event occurred (5/16/2023). The IRC Nursing Director stated he notified the Program Director the same night and "...she took it from there..." The IRC Nursing Director reported RN #1 was the charge nurse when the event occurred. The IRC Nursing Director stated workplace violence had been discussed in the staff meeting on 6/5/2023, but additional education regarding abuse had not been completed or discussed.

During an interview on 6/5/2023 at 2:25 PM, in the IRC conference room, RN #2 stated a CNA came out of Patient #4's room asking for help. RN #2 reported the patient was laying on his stomach, sideways in the bed with his legs hanging off the bed. RN #2 reported RN #1 came in the patient's room and said "...if he just hadn't asked us to get his fat [explicative] up he wouldn't have fell over the bed..." RN #2 stated "...We were trying to figure out the best way to get him turned around..." RN #1 wanted to flip the patient over and turn his legs, but the patient's nurse (Licensed Practical Nurse-LPN #1) didn't agree. RN #1 told LPN #1 to shut the (explicative) up. RN #2 reported RN #1 grabbed the back of the patient's shirt and was trying to lift him off the bed. She kept pulling at the patient's shirt and the patient said "...I can't breathe..." RN #2 stated the patient's shirt collar was digging around his neck, so it was probably hard for him to breathe. RN #2 stated RN #1 told Patient #4 "...If you are yelling, you can breathe..." After Patient #4 was positioned in the bed, RN #1 started to leave the patient's room and said "...He [Patient #4] is such an [explicative], I hate him..." RN #2 reported Patient #4 stated "...I'm sorry head nurse [RN #1], I really apologize..." and was very teary after the incident. RN #2 reported LPN #1 notified the IRC Nursing Director and the Program Director of the incident between RN #1 and Patient #4. RN #2 stated the 2 CNA's who witnessed the incident reported it to the Program Director the following morning.

During an interview on 6/5/2023 at 3:40 PM, in the IRC conference room, CNA #1 stated Patient #4 was very hard to transfer and had been hard to please. When he moved to a different room he was by himself and "...was the sweetest man..." CNA #1 reported when Patient #4 tried to stand up, he gave out and went face first on the bed. All the nurses came to help get Patient #4 positioned in the bed. CNA #1 reported RN #1 called Patient #4 "...ugly names...lazy, fat A..." She stated the patient kept apologizing and was making sure no one was hurt. "...he kept saying he was sorry..." CNA #1 stated "...I was crying because of the way she [RN #1] was talking to him...Her tone of voice was screaming..."

During an interview on 6/5/2023 at 3:49 PM, in the IRC conference room, CNA #2 reported they were trying to get the patient to the bed safely. "...It really got ugly...[RN #1] actually cursed..." RN #1 kept telling the patient to "...stand up, stand up...you do it in therapy...stand up, you big fat [explicative]..." The patient told RN #1 he couldn't do it. "...I felt so sorry for him. He was very teary..." CNA #2 stated everything was reported to the Program Director because the nursing director was on vacation.

During an interview on 6/5/2023 at 4:00 PM, in the IRC conference room, LPN #1 stated "...It was a horrible experience..." LPN #1 stated staff were transferring Patient #4 from the wheelchair to the bed. He had tipped over and the 2 CNAs couldn't get him back up to get him turned around and on the bed. LPN #1 stated RN #1 stuck her foot behind the patient's foot and told him to straighten his leg and lift his foot. Patient #4 told RN #1 that he couldn't lift his foot. RN #1 said "...well you walk...I know you can lift your foot...told the man he was lying...she knew he could walk..." LPN #1 stated at one point RN #1 told the patient to "...shut the [explicative] up..." RN #1 grabbed the patient by his shoulders and was trying to pick him up. LPN #1 didn't hear Patient #4 say RN #1 was choking him but "...I was screaming at her telling her to stop, let him go...he can't breathe...his face was going purplish/red..." LPN #1 stated RN #1 called Patient #4 a "...fat [explicative]..." as she walked out of the room. LPN #1 reported Patient #4 kept apologizing. "...He literally cried himself to sleep..." LPN #1 reported the incident occurred at shift change and she notified the IRC nursing director by telephone after she left the facility. "...It made me so sick...I called in sick the next day with a migraine and throwing up..." LPN #1 reported RN #1 kept trying to apologize and would say she was just trying to protect us and keep anyone from getting hurt.

Attempted to contact Patient #4 on 6/5/2023 at 6:34 PM, Patient #4's spouse stated the patient was residing in a skilled nursing facility and would not be able to speak with me. The patient's spouse reported a nurse cussed at him and grabbed at the collar of his shirt while he was in the IRC. She reported Patient #4 was working hard trying to come back home. Patient #4 told her "...I just gave up..." after the incident occurred. "...He just gave up and said there was no point..."

During an interview on 6/6/2023 at 10:18 AM, in the IRC Program Director's Office, the IRC Program Director stated the CNA's notified her of the incident involving Patient #4 and RN #1 the following morning (5/17/2023). She was told the charge nurse (RN #1) went in the patient's room and started yelling and telling the patient he should have stayed in the chair. The Program Director stated the incident occurred on 5/16/2023 at approximately 5:30 PM, and she was notified on 5/17/2023 at approximately 10:00 AM. The Program Director sent an email to the CNO and Compliance Director on 5/17/2023 at 11:30 AM, and asked for access to event reports due to a reported incident. Her request was forwarded to the Risk Manager. The Risk Manager sent the Program Director a screenshot of what had been entered in the facility's reporting system on 5/17/2023 at 12:25 PM. The Program Director began interviewing staff and taking statements on 5/17/2023 at 10:00 AM. The Program Director stated Patient #4 did not want to give her a statement but told her he could remember a lot of yelling and he just wanted to get back in bed and just fall asleep. The Program Director told the patient that RN #1 would not be coming back into his room and told another RN that she would need to assume the care of Patient #4. The Program Director told RN #1 that she didn't need to be in the patient's room and to not be involved in the patient's care. When asked if she thought the RN's behavior was actual abuse, the Program Director responded "...I feel like it was..." The Program Director confirmed RN #1 was not removed from the area immediately following the incident and confirmed RN #1 was permitted to work scheduled shifts following the incident.

During a telephone interview on 6/6/2023 at 11:18 AM, RN #3 stated the CNAs were unable to get Patient #4 back in the bed. She reported the patient was half in the bed and half out of the bed. RN #3 stated the patient was panicked saying he couldn't breathe. RN #3 stated RN #1 was telling the patient he needed to stand up and the patient was yelling that he couldn't breathe. "...It was really chaotic...She [RN #1] was loud...I don't quite remember everything that was said...there was a lot of yelling...I did hear her say 'Damn it...you need to stand up'..." RN #3 stated that RN #1 said she wasn't going to tolerate him yelling at staff when he was capable of standing. RN #1 also said the reason she was so stern with Patient #4 was because Physical Therapy had assured her the patient could stand. RN #3 stated "...It was more dramatic than what I was used to..."

During a telephone interview on 6/6/2023 at 11:50 AM, RN #1 (AP) stated she was the charge nurse on the evening of the incident with Patient #4. RN #1 stated "...I ran in the room...he was bent over the side of the bed...left leg was very forward...right leg was far behind him. He kept screaming he was going fall...told him he wasn't going to fall..." RN #1 reported the patient was very difficult and had been very ugly and abusive to staff earlier in the week. She stated the patient asked if they could just roll him over onto the bed. "...I was told that one of the nurses was yelling at me telling me we couldn't do that..." RN #1 admitted telling Patient #4 "...If you can yell at us...you are breathing..." She stated she told the patient to give her a minute to get him up in the bed. RN #1 stated she walked out of the room after the patient was in the bed. RN #1 stated "...I did not even know until a week later that I had apparently said some very inappropriate things to him...They told me I said something about getting your fat A in the bed...I swear to you that I didn't know those words came out of my mouth...Of course I know that is not anything you should ever say to anyone...I'm really sorry that I had a moment that I had just lost it...The bottom line is...I'm sorry...I didn't intend for those words to come out of my mouth..." RN#1 confirmed she finished her shift that day (5/16/2023) and confirmed she worked the following Friday, Saturday, Sunday, and Monday after the incident. RN #1 confirmed she went into the patient's room to apologize to him and stated no one told her to stay out of Patient #4's room.

During an interview on 6/6/2023 at 11:51 AM, in the conference room, the ACNO stated employees typically were not permitted to work until an investigation for an allegation of abuse was completed. The ACNO confirmed she was not aware of the incident involving RN #1 and Patient #4 until 5/22/2023. If she had been notified on 5/17/2023, she would not have permitted RN #1 to work pending the results of the investigation. The ACNO reviewed RN #1's time punches and confirmed RN #1 worked on 5/19/2023, 5/20/2023, 5/21/2023, and 5/22/2023.

During an interview on 6/6/2023 at 12:48 PM, in the conference room, the Chief Human Resources Officer (CHRO) stated Risk Management were expected to notify Human Resources (HR) of any allegation of abuse and an investigation would be initiated. Typically, the employee would not be permitted to work pending the results of the investigation. The CHRO stated "...I wouldn't have let her [RN #1] work if I had known about it...would have suspended until an investigation was completed...serious allegation or incidents...abuse would require immediate suspension or termination...they should have called me as soon as the allegation was made..." The CHRO stated the facility's procedure for allegations of abuse and protection of patients during an investigation for an allegation of abuse was not followed.