HospitalInspections.org

I. Based on document review and staff interview, the acute care hospital's administrative staff failed to ensure that a Patient Care Tech (PCT) was separated from all patients after the hospital was notified that the PCT was under investigation for alleged dependent adult abuse. Please see A-0144 for additional information.

The cumulative effect of these failures and deficient practices resulted in the hospital's inability to ensure all patients received care in a safe setting.

The hospital identified a census of 634 patients on entrance, and an average daily census of 44 in the Behavioral Health Unit.



II. During the complaint survey that ended on 10/07/20, the survey team identified an Immediate Jeopardy (IJ) situation (a crisis situation that placed the health and safety of patients at risk) related to the Condition of Participation for Patient Rights (42 CFR 482.13). The hospital's administrative staff failed to ensure that a PCT was separated from all patients after the hospital was notified that the PCT was under investigation for alleged dependent adult abuse.

The survey team identified an Immediate Jeopardy (IJ) situation and notified the administrative staff on 10/02/20. The administrative staff promptly took action to remove the immediacy of the situation. The hospital staff removed the immediacy prior to the survey team exiting the abuse investigation when the administrative staff took the following actions:

a. The involved employee was placed on paid leave.

b. An email was sent out on 10/6/2020 to the Management Team communicating the need to remove involved employee(s) from patient care during an internal and/or external investigation for potential abuse. The Outlook voting button was to be used to document the management team received and read the message.

c. The Child/Dependent Adult Abuse policy will be reviewed on 10/06/20 and revised if necessary to assure employee(s) are removed from patient care whenever there is notification of an abuse investigation.

d. Education regarding provider response to suspected abuse & investigations will be provided to the Supervisors Forum on 10/9/2020. Meeting attendance will be captured.

e. Education regarding provider response to suspected abuse & investigations will be provided to the Nursing Leadership Forum on 10/13/2020. Meeting attendance will be captured.

f. Education regarding provider response to suspected abuse & investigations will be provided to the Management Team on 10/15/2020. Meeting attendance will be captured.

g. If there are Management Team members identified that have not received the education as outlined above (i.e. those on Leave Of Absence) they will complete a NetLearning upon their return to work.

Based on document review and staff interview, the hospital's administrative staff failed to ensure 1 of 1 Patient Care Techs (PCT A) was separated from patients after the hospital was notified that PCT A was under investigation for alleged dependent adult abuse related to the care of Patient #1. Failure to separate PCT A from patients resulted in the administrative staff allowing PCT A to continue to work with dependent adults after it was identified that PCT A committed possible dependent adult abuse.

The hospital administrative staff identified a census of 634 patients on entrance, and an average daily census of approximately 12 patients in the Behavioral Health Geriatric Psych Unit.

Findings include:

1. Review of the policy "Child/Dependent Adult Abuse," dated 03/2020, revealed in part, "The following procedure is used to guide team members when possible abuse is identified ... If the alleged abuser is a team member, the Supervisor should assist in immediately removing the team member from patient care."

2. On Friday 10/2/2020 at approximately 4:00 PM, the Director of Behavioral Health was provided a document titled "Dependent Adult Abuse Notification to Facility or Program" which revealed in part, "Please be advised there has been an allegation of abuse of dependent adult(s), [Patient #1's name] against employee(s)/staff member(s) [PCT A's name] on or about May 8, 2020 at your facility/program. DIA [Department of Inspections and Appeals] will be investigating this allegation of dependent adult abuse." On 10/2/2020 at approximately 4:30 PM, the Director of Behavioral Health signed the document acknowledging receipt of the information that the DIA was investigating PCT A for possible dependent adult abuse.

3. Review of PCT A's timecard revealed PCT A clocked in on Sunday 10/4/2020 at 2:53 PM to work on the inpatient geriatric behavioral health unit (2 days after the hospital staff received notice that PCT A was under investigation for possible dependent adult abuse), and clocked out on 10/04/20 at 11:20 PM. (PCT A worked approximately 8.5 hours, after the hospital staff received notice that PCT A was under investigation for possible dependent adult abuse)

4. During an interview on 10/06/20 at approximately 10:40 AM, the Director of Behavioral Health acknowledged they received the Dependent Adult Abuse Notification to Facility or Program on 10/2/20. The Director of Behavioral Health also acknowledged that PCT A worked on Sunday 10/4/20 (2 days after the hospital received notice that PCT A was under investigation for possible dependent adult abuse). The Director of Behavioral Health also acknowledged that PCT A was scheduled to work the afternoon of Tuesday 10/6/20 (4 days after the hospital received notice that PCT A was under investigation for possible dependent adult abuse). The Director of Behavioral Health acknowledged that the patients on the inpatient geriatric behavioral health unit qualified as dependent adults, and that the hospital staff alowed PCT A to work (and was planning to continue allowing PCT A to work) with dependent adults, even after the Director of Behavioral Health received a written notice that PCT A was being investigated for dependent adult abuse of a patient in the inpatient geriatric behavioral health unit.