HospitalInspections.org

Based on review of the facility policies and procedures, quality assurance data and staff interviews, it was determined that the facility failed to ensure that the causes of adverse patient events were thoroughly investigated and analyzed, and that preventive actions were implemented that included feedback and education throughout the hospital.

Findings were:

Review of the facility's policy and procedure entitled Patient Rights, policy number 16-6-H, revised 09/06/2012, revealed that any abuse or neglect of a patient by a hospital employee will be investigated immediately through the offices of the CEO, Risk Management and Human Resources and processed through the Patient Care Concerns Subcommittee. An incident report will be completed. If the allegations are substantiated, this will be grounds for immediate dismissal.
Interview with credential file physician #1 on 08/26/2015 at 9:40 a.m. in the administrative conference room. Physician #1 recalled the patient (#4) and stated that he/she only saw patient #4 for 5-6 days while the patient was an inpatient in the hospital. The M.D. stated that the patient alleged that a male staff, employee #3, a Clinical Assitant (CA) touched her/him inappropriately and pulled down her/his blouse, and that this employee (#3) walked into her/his room while she/he was dressing. The M.D. told the patient to write it up on a Patient Concern Form, and that he/she informed the charge nurse, RN #1 about the incident. Physician #1 stated that the patient gave him/her a copy of the complaint form, and that he/she gave it to employee #8, the unit supervisor through the unit clerk. The physician stated that he/she had no knowledge of any past similar behaviors of this patient.
Interview with RN #1 on 08/25/15 at 2:30 p.m. in the administrative conference room. She/He was employed at facility for 10 years as staff nurse on Detox Unit C-2 on days On 08/04/15, patient #4 complained to her/him and she/he made a notation in the medical record. She/he then gave the patient a Patient Care Concern Form to fill out her/his complaint. When the patient completed the form, she/he turned it in to her/his manager, employee #8, and referred it to the patient's Case Manager. She/he reassured the patient at that time.
Interview with Employee #3, CA on 08/25/15 at 3:55 p.m. in the administrative conference room. She/He was employed 3 years in November and works Full Time on C-2 (adult inpatient addiction unit). Employee #3 called his supervisor, employee #8, and left a message on her/his phone concerning the allegation and the supervisor called him/her back, and that he/she told the supervisor that it did not happen.
Interview with Employee #6 on 08/25/15 at 4:15 p.m. in the administrative conference room. Employee #6 stated that she/he had been employed 2 ½ years on C-2 and worked the day shift. RN #6 stated that the procedure they followed when a patient alleged abuse was the following:
1. Talk with patients, as patients are sometime heavily medicated and are confused
2. Call the unit supervisor
3. Have patient fill out a Care Concern form
4. Give the form to the unit supervisor
5. Send information to the director of the unit
During an interview on 08/25/15 at 4:40 p.m. in the administrative conference room, Employee #12 stated that she/he did not report the incident as everyone knew about it and that she/he did not document it either.
Interview with Employee #13, CA on 08/26/2015 at 8:30 a.m. in the administrative conference room. Employee #13 stated that he/she has worked at facility for over a year and works nights (11-7). Employee #13 stated that patient #4 had no complaints. He/she stated that if a patient would allege something to him, that he/she would report it to employee #8, the unit supervisor, and use the chain of command.
Interview with Employee #7, RN on 08/26/2015 at 8:50 a.m. in the administrative conference room. Employee #7 stated that she/he has worked at facility for 2 years and works nights. Employee #7 stated that patients fill out a sheet (Daily Inventory Sheet), and that patient #4 wrote on her/his Inventory Sheet that she/he had homicidal ideations (HI)(desire to kill) about Employee #3. Employee #7 did not say whether she reported this incident to anyone.
Interview with Employee #8, RN on 08/26/2015 at 10:20 a.m. in the administrative conference room. Nurse Manager of the adult inpatient service. Employee #8 stated that she/he was out of the hospital 07/31/15 to 08/04/15. She/He stated that the first she/he was aware of the problem was a voice mail from employee #3 informing her/him that a patient (#4) had complained about him/her. Employee #8 stated that she/he went to the Unit and called employee #3 back to find out what had happened. She/He was told that over the weekend, patient #4 was impaired, and it appeared that patient #4 was on more than her/his regular medications. Patient #4's physician was called to check her/him. Employee #8 was told that employee #3 confronted the patient after the incident, as he/she felt it was a safety issue if patient #4 had traded medications with another patient. Employee #8 stated that the patient became angry, and the next day (Tuesday), employee #11 told employee #3 that the patient was really mad. Employee #8 stated that when she/he went to the unit, employee #1 told her/him the same thing. Employee #1 told her/him that on that Sunday, that the patient had to be put in a wheelchair for safety as she was unable to walk.
Employee #8 stated that on Tues (08/04) or Wed (08/05) she/he asked employee #1 about the time frame of the incident, and she stated that the patient alleged that the incident happened in the evening and that employee #3 only worked days. She/He stated that she/he interviewed employees #3 and #1, reviewed the chart and tried to talk with patient #4, but patient #4 would not talk to her/him.
Interview with Employee #9, licensed certified social worker (LCSW) on 08/26/2015 at 11:10 a.m. in the administrative conference room. Served as Patient Relations Coordinator. Has been employed at facility for 22 years. Employee #9 stated that the process that they use for complaint investigation is that when they receive a patient complaint, the staff that hears the complaint attempts to solve it at the unit level. The patient is interviewed and that goes to the nurse manager. The Unit Supervisor investigates the complaint and the patient fills out a Patient Care Concern Form. Employee #9 stated that she/he sometimes calls a patient after discharge to follow up. Employee #9 stated that in this particular case, that this particular staff was not on the unit in the evening. She/He stated that she/he called the unit supervisor (#8) and that they talked through the incident and that employees #1 and #3 were interviewed, and it was determined that this did not happen. She/He stated that the investigation would then go to Human Resources.
Interview with Employee #4, CA (telephone) on 08/26/2015 at 12:30 p.m. Employee #4 stated that she had worked at facility for 1 1/2 years and was presently in nursing school. Employee #4 stated that if a patient complained, that it was taken immediately to the nurse and that she would follow the nurse's directions.
Interview with Employee #5 on 08/27/15 at 12:35 p.m.(telephone) and has been employed at the facility for over 2 years. Employee #5 stated that she/he told patient #4 to fill out a patient complaint form.
Interview with Employee #10, Director of Administrative and Clinical Services, Risk Manager on 08/27/2015 at 2:00 p.m. in the administrative conference room. Employed at facility for 12 years. Employee #10 stated that she/he did not hear about this complaint until the present time. She/He had not been notified of this patient's complaint. She/He stated that the unit manager usually contacts her/him and sends her/him the incident report and that she/he would handle the investigation. This did not happen in this particular case.
Review of the interview noted above and on the investigation by the unit supervisor (employee #8) revealed that the supervisor then went to the unit and interviewed the RN (#1) and they looked at the schedule. The patient had specified that the incident occurred in the evening. It was determined that employee #3 did not work the evening shift. RN #1 was asked to document her/his findings. The supervisor stated that after reviewing the information and the schedule, it was determined that it was not possible that this incident occurred. She/he stated that when she/he received the Patient Care Concern Form, the patient was already discharged. She/he forwarded the information to the patient advocate (employee #9).
Review of the facility's process revealed that the Risk Manager (employee #10) had not been notified of the allegation (as required by the facility's policy). The unit supervisor (employee #8) interviewed the RN (employee #1) and employee #3 (the accused employee) only. Employee #8 determined that the incident did not occur based only on the fact that the patient alleged that the incident occurred in the evening and that employee #3 did not work evenings. The other allegation that the patient made (staff pulled up her/his shirt and touched her breasts) in the hallway on the way to lunch was not investigated. All of the staff with knowledge of this incident were not interviewed.
During the interviews, employees were asked about the facility's policy on reporting patients' serious allegations (abuse/neglect). Some employees did not know what to do or were not sure what the correct procedure was. Answers to what they would do differed widely. Employee #3 remained on the C-2 unit and had further contact with the patient before the investigation was completed.
Review of the Patient Care Concern Form completed by patient #4 (not for release) revealed that patient #4 alleged that employee #3 grabbed his/her blouse while walking in the hall and pulled it and snapped it back. Later that day, when she/he was taking clothes out of the suitcase, she/he was dressed in panties and a tank top, and employee #3 came in to her/his room, did not knock and did this five (5) times.
Review of a statement on the investigation by the unit supervisor (employee #8), not dated/timed, noted that she/he was out of the office on 08/03/15 and returned on 08/04/15. On the voice mail was a message from employee #3 calling to inform the supervisor regarding a possible patient complaint. The supervisor returned his/her call immediately. Employee #3 had been in and out of her/his room while she/he was wearing only a T-shirt and bra. The supervisor thanked him for the information, and assured him/her that she/he would investigate.
The supervisor then went to the unit and interviewed the RN (#1) and they looked at the schedule. The patient had specified that the incident occurred in the evening. It was determined that employee #3 did not work the evening shift. RN #1 was asked to document her/his findings. The supervisor stated that after reviewing the information and the schedule, it was determined that it was not possible that this incident occurred. She/he stated that when she/he received the Patient Care Concern Form, the patient was already discharged. She/he forwarded the information to the patient advocate (employee #9).
Review of the facility's investigation revealed that the Risk Manager (employee #10) had not been notified of the allegation (as required by the facility's policy). The unit supervisor (employee #8) interviewed the RN employee #1 and employee #3 (the accused employee) only. Employee #8 determined that the incident did not occur based only on the fact that the patient alleged that the incident occurred in the evening and that employee #3 did not work evenings. The other allegation that the patient made (staff pulled up her/his shirt and touched her/his breasts) in the hallway on the way to lunch was not investigated. All of the staff with knowledge of this incident were not interviewed.









Review of staff interviews revealed that employees were asked about the facility's policy on reporting patients' serious allegations (abuse/neglect). Some employees did not know what to do or were not sure what the correct procedure was. Answers to what they would do differed widely. Employee #3 remained on the C-2 unit, and had further contact with the patient before the investigation was completed.


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