HospitalInspections.org

Based on interview and record review the facility failed to provide 1 of 1 patients who complained of abuse (patient # 7) with a prompt, through investigation and protect the patient from staff threats for making the abuse complaint, increasing the risk of staff abuse and intimidation for all patients. Findings include:

Policy Review:
On 4/9/13 at approximately 1500 the facility's policy titled Abuse & Neglect was reviewed.
Abuse and Neglect, policy RR #5, dated 3/2013, states:
"All apparent or suspected abuse and/or neglect of patients...must be reported immediately to the Recipient Rights Advisor. All alleged abuse/neglect of patients shall be investigated by the Recipient Rights Advisor."

On 4/9/13 at approximately 1530 the facility's policy titled Complaint and Appeal Process, was reviewed.
Complaint and Appeal Process, policy RR #1, dated 3/13 states:
1.f. "The Rights Advisor is responsible to determine if an investigation is warranted."
2.b. "Subject to delays involving pending action by external agencies (...)the office will complete investigations no later than 90 calendar days following receipt."

The Abuse and Neglect policy does not state that all allegations of patient abuse will be investigated or provide a timeframe for completing abuse investigations. A complaint investigation timeframe listed in the Complaint and Appeal Policy (90 calender days) does not satisfy the requirement in A-0145 for a "prompt" investigation of abuse allegations.

Record Review:
On 4/9/14 from 1100-1600 hours patient #7' clinical record and the Recipient Rights Log and file pertaining to patient #7's abuse allegation was reviewed, revealing:
1. Patient #7 was a minor.
2. A 3/20/14 Skin Assessment note, states that patient #7 has: "healing scratch to r (right) chest. scratch to r (right) forearm."
3. A 3/21/14 Skin Assessment note, states: "patient (#7) had multiple scratches to body (left face, right arm..." (on the printed version of this on-line form it was unclear whether there was more documentation typed in this note.)
4. A 3/21/14 note by Nurse F, timed 1725 states: "Mom of (patient #7)...alleging abuse of her son. Patient does have slight bruising of upper right arm, scratch under left breast and small abrasion under left eye."
5. The above e-mail (dated 3/21/14), stating the abuse allegation, was sent to the Recipient Rights Advisor (staff B), named in the Abuse and Neglect policy as the person responsible for the investigation.
6. A "Recipient Rights Complaint Form," dated 3/21/14, states: "My son stated that staff put these bruises on him due to being to aggressive."
7. In a note dated 3/22/14, Nurse G stated that she threatened patient #7 for making an abuse allegation, stating: "it was within the hospital's rights to investigate the claims and if they were found to be fraudulent, that (patient #7) could be charged with making false police reports and accusations."
8. Staff B's interview notes with Patient #7, dated 3/24/14, quote patient #7 as stating: "(staff D) grabbing me and stuff-grabbing me and throwing me around w/ (with) door shut."
9. This abuse allegation, made verbally and in writing on 3/21/14, was not documented on the facility's Recipient Rights Complaint Log for March 2014.

Interviews:
1. On 4/9/14 at approximately 0925 staff B stated: "the (Recipient Rights Complaint) log is our way of keeping track of complaints that are still under investigation." Staff B confirmed that patient #7's complaint was not listed on the log.
2. On 4/9/14 at 1350 staff B, responsible for investigating the complaint (per the Abuse and Neglect policy), stated that this complaint investigation had not been completed. Staff B stated that all potential witnesses and the alleged abuser (staff D) had not been interviewed yet.
3. On 4/9/14 at approximately 1400 staff A confirmed that no other hospital investigation process to respond to the above abuse allegation had been completed and that no staff had been suspended during the investigation.