HospitalInspections.org

Based on record review, interview and policy review, the facility failed to log a grievance (A118), failed to ensure a proper abuse policy was developed to instruct staff on ensuring patient after staff to patient abuse allegations are made failed to ensure patient safety after a physical abuse allegation was made against staff by allowing the staff member to work with other patients prior to completing a proper investigation and failed to complete a thorough grievance investigation by not speaking to all involved parties (A145).

Based on staff interview and policy review, the hospital failed to ensure all grievances were properly logged in the Complaint/Grievance log. This affected one (Patient #1) of ten medical records reviewed. The census was 401.

Findings include:

Review of Patient #1's medical record revealed the patient arrived in the emergency department t(ED) on 04/20/22 at 11:52 PM via ambulance complaining of blood glucose concerns and a right ankle injury. The patient arrived unaccompanied via emergency medical services (EMS), and was a minor under the care of Franklin County Children Services (FCCS). The patient was diagnosed with hyperglycemia and had a history of diabetes.

Review of physician orders revealed the patient had a constant sitter providing one on one supervision which started on 04/21/22 at 6:14 AM related to the patient being a flight risk. On 05/01/22 at 4:17 PM the Licensed Social Worker (LSW) noted Patient #1 wants to leave but was told he cannot until FCCS has a safe place for him.

On 05/01/22 at 4:20 PM a Code Violet was called because Patient #1 was upset that he was unable to have visitors, unable to leave and the patient was upset about being hospitalized. Patient #1 requested CPS's phone number.

Review of a social work note dated 05/01/22 at 4:42 PM revealed the LSW (Staff Q) received a phone call from Patient #1's nurse stating the patient wanted the Child Protective Services (CPS) number. The LSW called FCCS and was given the number for the child abuse and neglect hotline (614) 229-7000 and instructed to push option #3. The number was then provided to the Patient #1.

Review of Staff J's (night shift LSW) notes revealed on 05/01/22 at approximately 11:00 PM the FCCS worker called and stated they received an anonymous call stating Patient #1 was abused by an hospital staff member and they wanted to ensure patient safety at this time. Staff J, noted FCCS did not provide a name for the perpetrator, but they provided a description, " tall, African American male, who was watching him as he cannot be left alone." The FCCS worker said it was the staff member that was with him last night (04/30/22). The FCCS staff member stated he/she was calling to ensure that Patient #1 was safe and to ensure the alleged perpetrator was not around the patient at this time. Staff J noted he/she contacted the nursing supervisor, who confirmed the patient's current constant attendant was a female. Staff J noted the FCCS caseworker informed him/her that the alleged abuse was physical. The patient was reported to have been hit with a fist, smacked in the arms, chest, and stomach causing small circles and a hand print on the patient's chest. Also bruising to the arms, back and stomach was reported. The medical team was made aware of the concerns for physical abuse and a physical exam was completed on 05/02/22 at 12:30 AM. The medical team reported to Staff J on 05/02/22 at 12:30 AM that there were no pertinent physical findings at that time. Pictures were taken during the assessment and there were no concerns noted.

Review of the Complaint/Grievance log for the past three months revealed no complaints were received related to concerns of staff to patient abuse or related to Patient #1.

During interview on 05/05/22 at 10:05 AM with Staff H revealed he/she was recently made aware of an abuse allegation being made against a staff member by a patient. Staff H stated she/he was not here for the event, but the patient did not notify floor staff of the abuse allegation, he/she notified an outside agency. Staff H stated the patient called the Child Protective Services (CPS) hotline. Staff H stated he/she was informed of the incident during a care conference or safety huddle. Staff H stated the patient was making threats about running and hurting staff. Staff H stated Patient #1 accused the constant attendant and added "they have worked together a lot of times with no issues noted." Staff H stated management has more information on the matter.

During interview on 05/05/22 at 11:24 AM with Staff F (Senior Clinical Risk Manager) and Staff L (Senior Associate General Counsel) revealed a FCCS worker contacted the night shift social worker on 05/01/22 around 11:00 PM informing that they had received an anonymous complaint that a black, tall, male, constant attendant physically assaulted Patient #1 on 4/30/22 and they were calling to make sure that the patient was safe. Staff immediately went to check on Patient #1 who was in his room with a female constant attendant. A head-to-toe assessment was completed on Patient #1 on 05/02/22 at 12:30 AM and there were no signs of abuse noted. Staff F stated the patient was then moved to unit C5A where there was consistent camera monitoring available. Staff F stated they were able to identify who the constant attendant was because the constant attendant, Staff K was the only African American male constant that was with the patient during the time in question. Staff K was interviewed and denied all allegations. Staff F stated Staff K said the patient was upset because he wanted to use Staff F's cell phone. Staff F stated the patient was trying to bargain with him/her to encourage the staff member to let him to use the phone. Staff F stated the patient escalated, the nurses came to calm the patient down and the rest of the night was uneventful. Staff F stated they did not log the grievance on the complaint log because the complainant was anonymous and there was no place to put it. Staff F and Staff L verified that the patient was positively identified, and a description was provided of the staff member when the FCCS worker called to inform the hospital of the allegation. Staff F stated they did not interview Patient #1 and were not planning to because the patient did not report any abuse to the hospital and due to the nature of the complaint, they did not feel it was appropriate. Staff F said the investigation is on-going.

Review of the hospital policy titled "Complaint and Grievance Resolution", last revised August 2020, revealed any employee who is aware of a concern will immediately attempt to resolve the matter. If the matter is resolved to the customers satisfaction, no further action is necessary. If the concern cannot be resolved quickly to the customer ' s satisfaction, or when a customer prefers to discuss the issue with someone other than the unit manager or supervisor, the staff member will contact the Patient Relations Coordinator (PRC). The PRC will contact the customer and attempt to address the concern. If the PRC cannot resolve the issue, the PRC will institute the grievance procedure. If a patient care concern cannot be resolved at the time by staff present, is postponed for later resolution, is referred to other staff for later resolution, requires investigation, and/or requires further actions for resolution, the concern is a grievance. Employees who receive notice of a grievance will immediately forward the information to Quality Improvement Services (QIS) and their relevant Manager/Director or Physician Leader for resolution. The Manager/Director is responsible for investigation and timely resolution of grievances within their respective areas. An initial written response to the customer will be sent to the customer if the grievance cannot be resolved within 7 calendar days. All investigations shall be completed within 30 days and a final written response is to be sent to the customer. Any grievance that may have caused harm to a patient will follow the Clinical Safety Event policy. QIS will be responsible for tracking all grievances and ensuring that responses are sent in a timely manner. A grievance is a formal or informal written, verbal or telephone concern that is made to the hospital by the patient or patient's representative regarding the patient's care, abuse, neglect, patient harm, issues related to the hospital's compliance with the CMS Hospital Conditions of Participation (CoPs) or a Medicare beneficiary billing complaint. QIS is responsible for coordinating and tracking the resolution and completion of customer complaints and grievances.

Based on record review, interview and policy review, the hospital failed to ensure the abuse policy directed staff on how to ensure patient safety after a staff to patient abuse allegation is made, failed to interview all parties involved in a complaint allegation and failed to ensure patient safety by removing the alleged perpetrator until a thorough investigation was completed. This affected one (Patient #1) of ten medical records reviewed. The census was 401.

Findings include:

Review of Patient #1's medical record revealed the patient arrived in the emergency department t(ED) on 04/20/22 at 11:52 PM via ambulance complaining of blood glucose concerns and a right ankle injury. The patient arrived unaccompanied via emergency medical services (EMS), and was a minor under the care of Franklin County Children Services (FCCS). The patient was diagnosed with hyperglycemia and had a history of diabetes.

Review of physician orders revealed the patient had a constant sitter providing one on one supervision which started on 04/21/22 at 6:14 AM related to the patient being a flight risk. On 05/01/22 at 4:17 PM the Licensed Social Worker (LSW) noted Patient #1 wants to leave but was told he cannot until FCCS has a safe place for him.

On 05/01/22 at 4:20 PM a Code Violet was called because Patient #1 was upset that he was unable to have visitors, unable to leave and the patient was upset about being hospitalized. Patient #1 requested CPS's phone number.

Review of a social work note dated 05/01/22 at 4:42 PM revealed the LSW (Staff Q) received a phone call from Patient #1's nurse stating the patient wanted the Child Protective Services (CPS) number. The LSW called FCCS and was given the number for the child abuse and neglect hotline (614) 229-7000 and instructed to push option #3. The number was then provided to the Patient #1.

Review of Staff J's (night shift LSW) notes revealed on 05/01/22 at approximately 11:00 PM the FCCS worker called and stated they received an anonymous call stating Patient #1 was abused by an hospital staff member and they wanted to ensure patient safety at this time. Staff J, noted FCCS did not provide a name for the perpetrator, but they provided a description, " tall, African American male, who was watching him as he cannot be left alone." The FCCS worker said it was the staff member that was with him last night (04/30/22). The FCCS staff member stated he/she was calling to ensure that Patient #1 was safe and to ensure the alleged perpetrator was not around the patient at this time. Staff J noted he/she contacted the nursing supervisor, who confirmed the patient's current constant attendant was a female. Staff J noted the FCCS caseworker informed him/her that the alleged abuse was physical. The patient was reported to have been hit with a fist, smacked in the arms, chest, and stomach causing small circles and a hand print on the patient's chest. Also bruising to the arms, back and stomach was reported. The medical team was made aware of the concerns for physical abuse and a physical exam was completed on 05/02/22 at 12:30 AM. The medical team reported to Staff J on 05/02/22 at 12:30 AM that there were no pertinent physical findings at that time. Pictures were taken during the assessment and there were no concerns noted.

Review of a nursing note dated 05/02/22 at 2:00 AM revealed the 11B Charge RN notified Patient #1's nurse that there was an anonymous complaint filed to CPS that Patient #1 was physically harmed by a staff member who was sitting one on one with the patient. The staff nurse was instructed to move the patient to C5A where camera monitoring may be provided. The 11B Charge RN called a proactive Code Violet. The patient refused to leave and code violet staff and a security officer spoke with Patient #1. Staff called the nursing supervisor who stated the patient could stay on H11B at this time with every 30 minute security rounds. Nursing orders were updated to reflect the patient was to have two staff members present at all times.

During interview on 05/05/22 at 1:38 PM, Staff A stated the hospital does not have a policy that directs staff on what to do to ensure patient safety during an abuse allegation. Staff A verified that there was no policy or written instruction to staff on how staff should provide immediate protection to the patient from the alleged perpetrator or how staff will ensure that no other patients are affected by the accused staff member. Staff A stated staff knows to protect the patient. When asked how he/she can ensure that staff is aware of protecting the patient, Staff A said they would know to protect the patient. Staff A verified staff is not trained on ensuring patient safety after an allegation of staff to patient abuse.

Review of the Complaint/Grievance log for the past three months revealed no complaints were received related to concerns of staff to patient abuse.

During interview on 05/05/22 at 10:05 AM, Staff H stated he/she was recently made aware of an abuse allegation being made against a staff member by a patient. Staff H stated she/he was not here for the event but the patient did not notify floor staff of the abuse allegation, he notified an outside agency. Staff H stated the patient called the Child Protective Services (CPS) hotline. Staff H stated he/she was informed of the incident during a care conference or safety huddle. Staff H stated the patient was making threats about running and hurting staff. Staff H stated Patient #1 accused the constant attendant and added "they have worked together a lot of times with no issues noted."

During interview on 05/05/22 at 11:24 AM with Staff F (Senior Clinical Risk Manager) and Staff L (Senior Associate General Counsel) revealed a FCCS worker contacted the night shift social worker on 05/01/22 around 11:00 PM informing that they had received an anonymous complaint that a black, tall, male, constant attendant physically assaulted Patient #1 on 04/30/22 and they were calling to make sure that the patient was safe. Staff immediately went to check on Patient #1 who was in his room with a female constant attendant. A head to toe assessment was completed on Patient #1 on 05/02/22 at 12:30 AM and there were no signs of abuse noted. Staff F stated the patient was then moved to C5A where there was consistent camera monitoring available. Staff F stated they were able to identify who the constant attendant was because the constant attendant, Staff K was the only African American male constant that was with the patient during the time in question. Staff K was interviewed and denied all allegations. Staff F stated Staff K said the patient was upset because he wanted to use Staff F's cell phone. Staff F stated the patient was trying to bargain with him to encourage the staff member to let him use the phone. Staff F stated the patient escalated, the nurses came to calm the patient down and the rest of the night was uneventful. Staff F stated they did not log the grievance on the complaint log because the complainant was anonymous and there was no place to put it. Staff F and Staff L verified that the patient was positively identified and a description was provided of the staff member when the FCCS worker called to inform the hospital of the allegation. Staff F stated they did not interview Patient #1 and were not planning to because the patient did not report any abuse to the hospital and due to the nature of the complaint they did not feel it was appropriate. Staff F said the investigation is on-going.

During interview on 05/10/22 at 3:00 PM with Staff K revealed he has worked as a constant attendant for over ten years and has never been accused of abuse. Staff K stated he has worked with Patient #1 many times before and they get along fine. Staff K denied hitting Patient #1. Staff K stated the night of 04/30/22 he was Patient #1's constant attendant. The patient was asking Staff K to use his personal cell phone. Staff K refused. The patient tried to bargain, but Staff K said no. After some time the patient got upset and punched a wall and other staff came in to calm the patient. Staff K stated after that, the rest of the night was uneventful. Staff K stated he has been interviewed by his supervisor and legal services. Staff K stated he has worked since the issue as a constant attendant.

Review of Patient #1's constant attendant schedule from 04/21/22 through 05/05/22 revealed Staff K worked with Patient #1 on 04/29/22 at 11:00 PM through 04/30/22 at 7:30 AM. Staff K also worked with Patient #1 on 05/05/22 at 3:00 AM through 7:30 AM on C5A (behavioral health unit with consistent camera monitoring).

Review of the hospital policy titled "Complaint and Grievance Resolution", last revised August 2020, revealed any employee who is aware of a concern will immediately attempt to resolve the matter. If the matter is resolved to the customers satisfaction, no further action is necessary. If the concern cannot be resolved quickly to the customer ' s satisfaction, or when a customer prefers to discuss the issue with someone other than the unit manager or supervisor, the staff member will contact the Patient Relations Coordinator (PRC). The PRC will contact the customer and attempt to address the concern. If the PRC cannot resolve the issue, the PRC will institute the grievance procedure. If a patient care concern cannot be resolved at the time by staff present, is postponed for later resolution, is referred to other staff for later resolution, requires investigation, and/or requires further actions for resolution, the concern is a grievance. Employees who receive notice of a grievance will immediately forward the information to Quality Improvement Services (QIS) and their relevant Manager/Director or Physician Leader for resolution. The Manager/Director is responsible for investigation and timely resolution of grievances within their respective areas. An initial written response to the customer will be sent to the customer if the grievance cannot be resolved within 7 calendar days. All investigations shall be completed within 30 days and a final written response is to be sent to the customer. Any grievance that may have caused harm to a patient will follow the Clinical Safety Event policy. QIS will be responsible for tracking all grievances and ensuring that responses are sent in a timely manner. A grievance is a formal or informal written, verbal or telephone concern that is made to the hospital by the patient or patient ' s representative regarding the patient ' s care, abuse, neglect, patient harm, issues related to the hospital ' s compliance with the CMS Hospital Conditions of Participation (CoPs) or a Medicare beneficiary billing complaint. QIS is responsible for coordinating and tracking the resolution and completion of customer complaints and grievances.

Review of the hospital policy titled "Patient Rights and Organizational Ethics", last revised August 2020, revealed the hospital will respect the rights of every patient/family. All patients, including inpatients and outpatients, must be informed of their rights before the hospital provides or stops providing care. Staff is to request informed consent involving the patient/family in planning and decision-making in the course of treatment explaining the risks, benefits and alternatives in terms a patient/family can understand. For inpatients, outpatients in the Emergency Department/Urgent Care or patients who are undergoing same-day surgery, if age is 18 years or older, give information about Advanced Directives; if one exists, a copy must be placed on the patient's chart. Inform patients/family about complaint resolution through the Patient Family Resource Guide Administrator and/or Patient Relations Coordinator. Staff is to provide care in a safe setting and provide access to protective services upon request. When patients are unable to make decisions about their care, the hospital may involve a surrogate decision-maker to help with these decisions in accordance with law and regulation. All patients are given a list of Patients' Rights and Responsibilities. A poster of Patients' Rights and Responsibilities are in ambulatory care areas. Each patient has the right to access their medical records.

Review of the hospital policy titled "Mandated Reporting of Child Abuse, Animal Abuse, and Burn Injuries", dated May 2021, revealed any mandated reporter who knows or expects that a child under 18 years of age that reasonably indicates abuse or neglect of the child shall immediately report that knowledge or suspicion to the appropriate child protection and/or police agency. The child abuse physician and/or Legal Services may be contacted 24 hours a day 7 days a week for consultation regarding matters of suspected abuse or neglect. The practitioner, social worker or other licensed mental health clinician will document the indicators of suspected abuse in the electronic medical record (EMR). The physician and nurse caring for the patient are responsible for collecting, transporting and safeguarding any evidence of abuse. The social worker or licensed mental health clinician will notify departments that may become involved with a suspected abuse case. If an employee or another patient is suspected of abusing a child in the care of the hospital, staff is to notify a social work supervisor, notify legal services, report the suspicion to the county child protection agency and/or the appropriate police agency. Legal Services along with the employee's manager and Human Resources (HR) will determine whether the employee will be placed on investigative leave and/or to determine what limitations will be placed on that employees access to children at the hospital.

Review of the hospital policy titled "Constant Attendant", dated June 2011, revealed a practitioners order is required to initiate or discontinue a constant attendant. The order must include justification. The constant attendant must be in the patient's room at all times and maintain the ability to safely exit the room at all times. The door will maintain partially opened unless there is a modified order. The constant attendant will remain outside the door during clinical therapy. In the emergency department (ED) the constant attendant may sit in the doorway due to the size of the rooms. The constant attendant is not to engage into any activity that would absorb his/her attention and distract his/her focus on the patient. Light reading material is allowed.