HospitalInspections.org

Based on review of facility documents, medical records (MR), and interview with staff (EMP), it was determined the facility failed to ensure possible patient abuse was reported to the appropriate agency for one of 20 medical records reviewed (MR1).

Findings include:

Review of the facility's "Rights and Responsibilities of Patients," dated revised October 2011, revealed "1. Purpose a) Moses Taylor Hospital is committed to providing care and service of the highest quality for children and adults, and to assuring that the basic human rights of expression, decision and action, and personal dignity are preserved for our patients. ... This policy applies to all patients. ... Your Rights ... As a patient at Moses Taylor Hospital, you or your legally responsible party have the right to receive care without discrimination due to age, sex, color, religion, sexual orientation, income, education, national origin, ancestry, marital status, culture, language, disability, gender identity or who will pay your bills. As our patient, you have the right to safe, respectful and dignified care at all times. You will receive services and care that are medically suggested and within the hospital's services, its stated mission and as required by law and regulation. ... Care Delivery ... You have the right to: Receive care in a safe setting free from any abuse, harassment and neglect. ... Receive kind, respectful, safe quality care delivered by skilled staff..."

Review of the facility document "Community Resource Guide," updated July 2007, revealed "The following resources/services are listed to provide necessary help and further treatment for you after your hospital stay. ... Mental Illness and Mental Retardation ... B. Advocacy Alliance..."

Review of MR1 revealed the patient was admitted to the hospital on May 23, 2012, from another facility for symptoms of Acute Renal Failure, most likely related to their psychiatric medications. The patient presented to the Emergency Department with abrasions of his scalp and face. A rash was present on their extremities. The abrasions and rash were not documented on the transfer sheet from the transferring hospital. Documentation revealed the patient was a poor historian. Continued review of MR1 revealed the patient did have a history of falls at the transferring facility.

Further review of MR1 revealed no documentation the facility called the transferring facility to clarify the origin of the skin status or called the Advocacy Alliance to report a possible patient abuse issue.

Interview with EMP2 on July 3, 2012 at approximately 10:00 AM confirmed the facility did not contact the transferring facility regarding the status of the patient's skin.

Interview with EMP1 on July 3, 2012 at approximately 10:30 AM confirmed the facility did not call the Advocacy Alliance to report a possible patient abuse issue.

Based on review of facility policy and procedures, medical records (MR), and interview with staff (EMP), it was determined the nursing staff failed to follow policies and procedures for falls prevention for one of one medical records reviewed (MR1).

Findings include:

Review of the facility policy "Fall Prevention", last reviewed December 28, 2011, revealed "It is the policy of Moses Taylor Hospital to promote the safety and well being of all patients while maintaining and promoting optimal levels of independence. Communication of fall risk and current strategies to prevent falls to all caregivers, patients, and families/significant other is essential. ... Fall Risk Level ... 6. Patient and family/significant other are to be educated and updated ongoing basis as to fall risk and current interventions. ... 11. If a patient falls, complete the following: ... f. Communicate fall and increased risk to physician, other healthcare team members, family, and next shift."

Review of MR1 on July 3, 2012, at approximately 10:30 AM revealed the patient was identified at high risk for falls and was found sitting on the floor on May 25, 2012, with an abrasion of his mid back area. Continued review revealed a transfer sheet from the transferring facility identifying the patient's next of kin's phone number. Documentation in MR1 revealed "family member - none listed on admission form."

Interview with EMP2 on July 3, 2012, at approximately 11:00 AM confirmed the patient's next of kin was identified on the transfer sheet from the transferring facility. EMP2 further confirmed the family was not notified of the patient's fall.