HospitalInspections.org

This CONDITION was not met as evidenced by:

Based on a review of clinical records, review of hospital documentation, policies, and staff interviews for 1 of 3 sampled patients reviewed for allegation of abuse (patient #9), the hospital failed to ensure the patient was free from abuse and failed to ensure the staff was removed from patient care areas according to hospital policy.

Cross Reference:
482.13(c)(2) Patient Rights: Care in Safe Setting (A0144)
482.13(c)(3) Patient Rights: Free from Abuse/harassment (A0145)

Based on a review of clinical records, hospital documentation, policies, and staff interview for 1 of 3 sampled patients reviewed for injury, the hospital failed to administer safe care when a Certified Nurses' Aide (CNA) applied a hot pack to the patient resulting in a third degree burn. The finding includes:

Patient #68 was admitted to the hospital on 11/25/23 for back pain and lower extremity edema.
Review of hospital documentation dated 11/26/23 noted the patient was found with a left upper flank wound, the dermis pulled off, reddened and a small upper area noted with 3rd degree burns. The documentation identified 2 cold wet washcloths were found rolled up in a towel. The documentation further identified the patient reported asking for a hot pack earlier in the day and CNA #1 placed the hot washcloths on the patients back.

The nurse's notes dated 11/26/23 at 9:30 PM noted upper center of wound with greater loss of epidermis measurement 4cm by 7 centimeter (cm) with a depth of 0.15cm, binder on to keep dressing in place.

Review of the wound care notes dated 11/30/24 at 10:08 AM identified a 3rd degree wound to the patient's left upper back, measuring 16.5cm by 19cm by 0.1cm, the wound bed is 60% granulation tissue, 10% adherent yellow slough and 20% of the wound is a deep maroon eschar measuring 6.5cm by 7.5cm. The wound was treated and covered with a dressing.

Interview with the Quality Improvement Manager on 9/24/24 at 1:45 PM stated that the patient complained of back pain to the CNA, the aide then went to the RN to report it, but the RN was in the middle of a code with another patient. It was later identified that the CNA applied hot wash cloths to the patient's back. The Quality Improvement Manager indicated that the CNA should have gone to another nurse about the back pain before applying the wet washcloths. The Quality Improvement Manager indicated that if a patient requests or requires a hot pack, the RN would get a physician's order, apply the hot pack and then monitor the patient's skin during the application. The Manager further indicated that after the incident staff were educated on the hospital policy on the use of hot packs/Aquamat and were provided a demonstration of how to use it.

Review of the hospital Aquamat policy identified that Aquamat can only be used with practitioner/AHP order. Licensed nursing staff is responsible for the correct set up of the equipment. Area covered by aquamat is checked in 30 minutes after application for heat tolerance and every (2) hours thereafter.
RN #20 and CNA #1 were unavailable for interview.

Based on a review of clinical records, review of hospital documentation, policies, and staff interviews for 1 of 3 sampled patients reviewed for allegation of abuse (patient #9), the hospital failed to ensure the patient was free from abuse and failed to ensure the staff was removed from patient care areas according to hospital policy. The finding includes:


Patient #9 was admitted to the hospital on 8/13/24 for alcohol abuse and withdrawal.
Nurse's notes dated 8/17/24 at 6:11 AM identified that at approximately 4:45 AM patient #9 pulled off the tele leads and his/her central line. The note identified the patient was agitated, yelling, kicking at staff and equipment. The note identified security was called to assist with manual hold position while the patient was medicated. The patient was observed thrashing, kicking and attempting to spit at staff. The Advanced Practice Registered Nurse (APRN) was called to the bedside and the patient was again medicated. The note further identified the patient continued to kick and punch at staff and 4-point restraints were applied.

Review of the hospital documentation dated 8/17/24 noted the patient became agitated, pulling out lines, and security was called to hold the patient down for medication administration. The documentation noted that security guard #1 was observed to take the seizure pad off the bed and place it horizontally across the patient's face, holding pressure on top of the pad, pushing the patient's face down into the mattress and was yelling "shut up, if you don't shut up I'm going to punch you in the face". The security guard was swearing at the patient. The documentation further identified the patient was placed in 4-point restraints and the seizure pad was removed from his/her face.

Review of security guard #1's time sheet identified the security guard punched out from their shift at 8:00 AM (approximately 2 hours and 15 minutes after the security guard was observed yelling at patient #9 and holding the patient's head down with a seizure pad).

Review of security guard #1's badge swipe log dated 8/17/24 identified after the allegation of abuse was reported, security guard #1 swiped his badge numerous times between 5:27 AM and 7:44 AM going in and out of the ambulance bay in the emergency department (ED) and the main entrance in the ED into patient care areas.

Review of the administrative leave checklist dated 8/17/24 identified security guard #1 was placed on leave on 8/17/24.

Interview with security guard #2 on 9/19/24 at 1:55 PM indicated that she and security guard #1 were called to the unit to assist with a patient. Security guard #2 stated that security guard #1 pushed the patient's head into the mattress and placed a seizure pad on the patient's face, while the patient was saying "let me go" and security guard #1 was yelling and swearing at the patient. Security guard #2 stated that after the patient was restrained, she and security guard #1 left the unit and went back to the security office. Security guard #2 stated that because she was so flustered with what happened it did not occur to her to report what she observed.

Interview with RN #9 on 9/26/24 at 9:25 AM stated that she called security to assist with patient #9 because the patient was combative, threatening and pulling out lines. RN #9 stated that the patient attempted to spit at the security guard and security guard #1 became very agitated/yelling to the patient "I'm going to punch you in the face." RN #9 stated that security guard #1 took the seizure pad off the bed and began to smash it into the patients face. RN #9 stated that she told the security guard to remove the pad, the security guard said, "I'm not letting go, if he/she spits, I'm going to punch him/her in the face." RN #9 stated that after they got the patient restrained security left the floor and she reported the incident to the charge nurse. RN #9 further stated that she observed the charge nurse talking with the RN Supervisor but did not hear what was said and the RN Supervisor did not ask her anything about the incident.

Interview with RN #10 on 9/26/24 at 9:50 AM stated that she was in patient #9's room while the patient was being restrained and she observed security guard #1 holding a seizure pad on the patients face and yelling/swearing at the patient. RN #10 stated that RN #9 reported the incident to the charge nurse, and she was present when the charge nurse told the RN Supervisor that the security guard was rough and swearing at the patient. RN #10 stated that the supervisor reiterated the patient's behaviors and being in restraints but appeared focused on making sure there was staff available to do the one-to-one observation while the patient was in restraints. RN #10 stated that she and the charge nurse told the supervisor a second time what happened with patient #9 and security guard #1 but all the supervisor said was okay and left the area.

Interview with RN #11 (charge) on 9/24/24 at 7:40 AM identified that RN #9 and RN #10 reported that security #1 was rough, held the patient's head/face down with a seizure pad and was yelling and swearing at patient #9. RN #11 stated she reported to the RN Supervisor what had happened, and the supervisor said "okay". RN #11 stated RN #10 was present and reported the rough handling by the security guard to the supervisor. RN #11 stated that she completed the hospital documentation of the event but did not see the supervisor assess the patient and she did not know what was done.

Interview with RN #12 (RN Supervisor) on 9/24/24 at 9:30 AM identified that she was not told of the incident. RN #12 stated that if she was told of rough inappropriate handling, she would have followed the hospitals abuse policy.

Interview with the Director of Security on 9/19/24 at 2:15 PM stated that when it was reported to him that security guard #1 yelled at patient #9 and held the patient down using a seizure pad, he contacted the security guard and placed him on administrative leave.

Interview with the Director of Quality on 9/20/24 at 11:30 AM stated that she was reviewing hospital incident reports when she noted the report related to patient #9. The director stated that she reviewed the report and contacted the Director of Security, and security guard #1 was placed on administrative leave at that time.

Interview with the Chief Nursing Officer (CNO) on 9/20/24 at 12:10 PM stated that when she spoke with the RN Supervisor, the RN supervisor reported that she did not hear the word "inappropriate" during conversation with the charge nurse. The CNO stated that staff are aware of the hospital's abuse policy, and she felt there was a communication issue related to this incident. The CNO stated that the supervisors and charge nurses were educated at that time regarding communication and ensuring that they hear what was being said. The CNO further identified that security guard #1 remained on administrative leave.

Multiple attempts to interview security guard #1 were unsuccessful.

Review of the hospital abuse policy identified any form of suspected abuse or harassment allegations regarding a patient will be immediately reported to the manager, supervisor or director. The policy identified as soon as the allegation is known, in order to ensure the safety and well-being of those involved, the employee will be removed from patient care and patient care areas until the investigation is completed.