HospitalInspections.org

Based on record review and interview, the facility failed to document an incident for 1 (P-1) of 10 patients reviewed for patient rights, into the facility incident reporting system, resulting in the increased potential for unrecognized adverse outcomes and missed opportunities for tracking and trending of incidents. Findings include:

Review of document titled, "Confidential Report of Investigative Findings (RIF)," dated 05/21/25, revealed, "On 05/21/25, ORR received a complaint that the family of recipient (P-1) phoned the facility stating (P-1) was on (social media) live, being recorded naked while in the shower, family reported that you can hear an unknown male voice in the background in the video, the nursing manager (Staff Q) was able to obtain the video footage from the recipient phone to confirm the validity of the complaint." Further review of the report noted " ...It appears that the recipient did receive some assistance from a male staff whose voice is clearly heard in the video while recording naked and obscene sexual gestures, no other male staff outside of (Staff R) enter the recipient's room at any time during the time the video was recorded." The report also demonstrated finding that Staff R provided P-1 with her cell phone, in violation to facility policy.

On 07/07/25 at 1300, a review of the facility "Incident Log," dated 01/01/25-07/07/25 failed to demonstrate any incidents related to P-1 obtaining her phone or Staff R's alleged interaction with P-1. An interview on 07/07/25 at 1034 with Risk Manager (Staff J) confirmed that no incident was reported by staff regarding the code of conduct violations.

Review of facility policy titled, "Risk Management Incident Reporting Policy," #xxxx.RISK.0210, rev. 01/23, revealed, "The Incident Report is a Risk Management tool that raises awareness of actual or potential exposures to harm. The Incident Report enables the facility to manage risk, increase safety, and improve the quality of health care provided in the facility through risk control intervention and monitoring the effectiveness of the interventions and corrective action plan. The Incident Report will help the various facility committees and administration in identifying and analyzing potential areas of risk and implementing measures to improve the overall quality of care and promote a culture of safety throughout the facility." Further review under "4.0 Procedure," revealed, "Any facility staff member who witnesses, discovers, or has direct knowledge of an incident must complete an Incident Report before the end of the shift/workday. Under-reporting or failure to report a known incident is not acceptable. An "incident" is an unanticipated event which results in, or nearly causes, a negative impact on patient care or visitor safety. Any harm caused can be temporary, long-term, or permanent and range in severity from no obvious or significant injury, up to death."

Review of facility policy titled, "Abuse and Neglect," #RI 1.9, rev. 02/21, confirmed under "Definitions, (2.) Exploitation- An action by an employee, volunteer, or agent of the hospital that involves the misappropriation or misuse of a recipient's property or funds for the benefit of an individual, or individuals other than the recipient."