HospitalInspections.org

Based on interview and record review, the facility failed to implement their established policy and procedures to document and investigate allegations of reported verbal abuse and failed to report the allegations and the investigation findings to the State Agency for two allegations of verbal abuse for 2 (#s 2 and 3), and an elopement for 1 (#1) of 5 sampled patients; and failed to follow their established policies and procedures to provide on-going training to their employees on the prohibition and prevention of patient abuse for 1 (staff member N) of 7 reviewed personnel. This deficient practice has the potential to affect all patients receiving services at the facility. Findings include:

1. Investigating and Reporting Allegations of Abuse

A review of the facility's policy and procedure titled, Abuse, Neglect, and Exploitation Reporting, Investigation, and Protection, with a revision date of 2/8/21, showed:

- "... REPORTING PROCEDURE

4.1 An alleged violation involving abuse, neglect, exploitation or mistreatment, injuries of unknown source, and misappropriation of property are verbally reported immediately, and within 2 hours if there is alleged abuse or serious bodily injury has occurred to the Director of Nursing, or the Social Services designee, or the [Chief Executive Officer].

4.2 The staff member reporting the alleged violation shall additionally complete an incident in the electronic reporting system.

4.3 Within 24 hours, administrator or social services designee will report the alleged violation to the State Survey Agency. The initial "24-hour report form" for the state of Montana DPHH http://dphhs.mt.gov/qad/Certification. Certification Bureau...

6.0 INVESTIGATION

6.1 The facility Administrator, [Director of Nursing], Social Services, or the individual designated on their behalf will conduct a thorough investigation...

6.2 The results of the investigation must be reported to the certification bureau using the same electronic reporting system within 5 days of the initial incident.

6.3 The results of the investigation must be reported back to administration [Chief Executive Officer] or Director of Nursing.

6.6 Corrective action by the administration will occur depending on the results of the investigation and ongoing monitoring through [Quality Assurance Process Improvement] Committee..."

a. During an interview on 6/4/24 at 9:30 a.m., NF1 stated patient #2 was admitted to the facility at the end of October 2023. NF1 stated patient #2 had called her crying stating staff member N had told patient #2 that she was too overweight to be moved in her bed and she (staff member N) and her staff would not move her (patient #2). NF1 stated patient #2 had quit asking any of the staff for further help because of the comment. NFI stated she was upset by how patient #2 was treated by staff member N and reported the incident to staff member A but had never heard any follow up about the reported incident.

During an interview on 6/5/24 at 11:15 a.m., staff member A stated he did not recall an incident being reported to him regarding verbal abuse by staff member N towards patient #2. Staff member A stated it was the expectation that all incidents of abuse were reported, investigated, and depending on the nature of the abuse would be reported to the state agency.

A review of the facility's abuse reporting incidents from 10/1/23 through 6/5/24, failed to show that the incident was documented, investigated, or reported to the state agency.

b. During an interview on 6/4/24 at 2:00 p.m., staff member L stated she had overheard staff member F tell patient #3 that he was going to the bathroom too much and she would not help him to use the bathroom anymore. Staff member L stated she reported the incident to staff member N at the time of the incident.

A review of the facility's abuse reporting incidents from 10/1/23 through 6/5/24, failed to show that the incident was documented, investigated, or reported to the state agency.

During an interview on 6/5/24 at 11:15 a.m., staff member A stated he did not recall an incident being reported to him regarding verbal abuse by staff member F towards patient #3. Staff member A stated staff member N was the Director of Nursing (DON) at the time of the incident in question and she should have followed the facility's process on abuse investigation and reporting. He stated she was no longer the DON and only worked at the facility as "Casual" staff. Staff member A stated it was the expectation that all incidents of abuse were reported, investigated, and depending on the nature of the abuse would be reported to the state agency.

c. Review of the facility's abuse report incidents from 10/1/23 through 6/5/24, showed patient #1 had eloped from the facility on 5/13/24. The incident was reported and documented, and investigated, but was not reported to the state agency.

During an interview on 6/5/24 at 11:15 a.m., staff member A stated the elopement of patient #1 was reported and investigated but was not aware that it was a reportable incident and therefore it was not reported to the state agency. Staff member A stated patient #1 did not receive injury from the elopement and was redirected about not leaving the facility without assistance and no further incidents have since occurred.

2. Abuse Prevention Training

A review of the facility's policy and procedure titled, Freedom from Abuse, Neglect, and Exploitation, with a revision date of 2/8/21, showed, "1.0 PURPOSE
To prohibit abuse, neglect, and exploitation of all patients/residents of this facility by
educating employees to identify and prevent such incidents."

Review of the facility's personnel files for on-going abuse prohibition training showed staff member N completed an abuse prohibition training presented by Adult Protective Services on 3/9/24. Additional abuse training was assigned to staff member N titled, Awareness and Reporting of Patient Abuse on 3/1/24, which was not started or completed by staff member N, as of 6/4/24.

During an interview on 6/5/24 at 12:00 p.m., staff member R stated staff member N had transitioned to, "Casual" working status on 4/1/24, and had not completed the abuse prohibition training which was assigned on 3/1/24.

A review of facility's Time Worked Report showed staff member N had worked at the facility on 4/21/24.

During an interview on 6/5/24 at 12:00 p.m., staff member R stated it was the expectation that all staff working at the facility complete the abuse prevention training upon hire and annual thereafter.