HospitalInspections.org

Based on interview, review of the facility's "Patient Feedback Form" (grievance form), and review of the facility's "Abuse/Neglect" policy, it was determined the facility failed to ensure one of ten patients (Patient #6) had the right to be free from all forms of abuse or harassment. The facility failed to implement the "Abuse/Neglect" policy and failed to report and thoroughly investigate all allegations of abuse or harassment. On 12/01/11, Patient #6 reported an allegation of abuse or harassment by the family member of Patient #11 toward him/her to Certified Nursing Assistant (CNA) #2. Although the CNA reported the allegation to Registered Nurse (RN) #3, the RN failed to report the incident to the House Supervisor or initiate an investigation of the allegation. In addition, on 12/07/11, Patient #6's family member called the facility to file a complaint related to the patient's report of abuse or harassment. The facility failed to report the allegation of abuse/harassment to Administrative staff and to the appropriate state agencies as required, and failed to conduct a thorough investigation of the allegation.

The findings include:

Review of the facility's "Abuse/Neglect" policy (revised 05/17/10) revealed "Any person having reasonable cause to suspect that an adult has suffered abuse, neglect, or exploitation, shall initiate reporting immediately." The Reporting section of the policy revealed, "Team members are to immediately notify the House Supervisor or Department Director if abuse/neglect/exploitation is suspected." The policy revealed the Department Director or House Supervisor who received the report of suspected abuse/neglect/exploitation would ensure the Administrator, Department of Community Based Services (DCBS), Law Enforcement, and the Office of Inspector (OIG) were notified of the allegation and would initiate an internal investigation utilizing the "Investigation Tool for Allegation of Abuse, Neglect, and Misappropriation of Patient Property." The Investigation section of the policy revealed, "The nurse will obtain history of the abusive incident in the victim's own words, notify the House Supervisor, perform a thorough exam, document all finding in the medical record, and notify the appropriate agencies."

Review of a "Patient Feedback Form" revealed the Patient Service Representative received a complaint from Patient #6's family member on 12/07/11, at 1:00 PM, that the spouse of Patient #11 "cursed" and "shoved the bedside table" into Patient #6 causing the patient to fall back onto the bed on 12/01/11. Patient #6's family member reported the nurses "didn't do anything" and no one asked Patient #6 what happened. The review revealed the Patient Service Representative spoke to Patient #6 on 12/07/11, and was informed on 12/01/11, between 7:30 PM and 8:30 PM, Patient #11 had been admitted to the second bed in Patient #6's room. Patient #6 reportedly stood up from the bed, moved a bedside table to get his/her intravenous (IV) lines in position in order to walk to the bathroom, and the spouse of Patient #11 became upset and began to curse Patient #6. According to the report, Patient #6 attempted to explain the bedside table would be moved back upon his/her return from the bathroom; however, Patient #11's spouse continued to curse Patient #6, pushed the bedside table into Patient #6, and as a result, the patient fell onto the bed. The report revealed the Patient Service Representative apologized to Patient #6 and informed the patient the incident would be thoroughly investigated by the Director. According to the report, the Patient Service Representative informed the Unit Manager of the interview with Patient #6 and that the incident was reportedly resolved. Continued review of the Patient Feedback Form revealed, even though the patient interview revealed the incident had occurred on Thursday, 12/01/11, between the hours of 7:30 PM and 8:30 PM, the family member's complaint was discussed with the Unit Manager, the House Supervisor, Registered Nurse #4, and Registered Nurse #5 and were unaware of the allegation. However, there was no documentation of an abuse allegation investigation, that the nursing staff that provided care for Patient #6 on the evening of the incident on 12/01/11, had been interviewed, or that the incident had been reported to the Department Director, DCBS, Law Enforcement, or OIG.

Interview conducted on 12/15/11, at 7:30 PM, with the Director of the Third Floor revealed she was unaware of the allegation until 12/15/11.

Interview conducted on 12/15/11, at 4:35 PM, with the Patient Service Representative confirmed she received a complaint from a family member of Patient #6, had spoken to Patient #6, and was unable to find any documentation related to the incident. The interview revealed the Patient Service Representative interviewed Registered Nurses #4 and #5 who had worked on 12/07/11, and they were unaware of the incident. According to the Patient Service Representative, "anyone that mistreats a patient" was considered abusive, however the Representative stated this incident was not considered abuse because it did not involve an employee.

Interview conducted on 12/15/11, at 7:15 PM, with the Unit Manager revealed the Patient Service Representative made her aware on Thursday, 12/07/11, of the complaint voiced by the family member of Patient #6. The interview revealed the Unit Manager had not worked the weekend and had returned to work the following Monday. The Unit Manager reportedly interviewed Registered Nurses #4 and #5 who had worked on 12/07/11 and they were unaware of the incident. The Unit Manager acknowledged she had not discussed the incident with Registered Nurse #3, Certified Nursing Assistant #2, or the House Supervisor, all of which had worked on the evening shift of Thursday, 12/01/11, and were knowledgeable of the incident.

Interview conducted on 12/15/11, at 5:45 PM, with Registered Nurse (RN) #1 revealed the Registered Nurse had provided care to Patient #6 on the evening of the incident on 12/01/11, but had been on a "break" when the incident occurred. Registered Nurse #1 stated when she returned from break she was informed there had been an incident with Patient #6 and RN #3 had requested the House Supervisor come to the Unit to resolve the incident.

Interview conducted on 12/15/11, at 6:00 PM, with Certified Nursing Assistant (CNA) #2 revealed she had worked on the evening shift on 12/01/11, and had provided care for Patient #6. CNA #2 stated Patient #11 was admitted to the second bed in Patient #6's room and the spouse of Patient #11 was upset due to having to share a room. According to CNA #2, Patient #6 reported to the CNA that Patient #11's spouse became upset when Patient #6 moved the bedside table on Patient #11's side of the room in order to get out of bed, had cursed at Patient #6, and pushed the bedside table into Patient #6 almost knocking the patient down. The interview revealed CNA #2 reported Patient #6's allegation to RN #3.

Interview conducted on 12/15/11, at 7:50 PM, with Registered Nurse (RN) #3 revealed she had worked on the evening shift on 12/01/11, when Patient #11 was admitted to the second bed in Patient #6's room. Registered Nurse #3 stated the spouse of Patient #11 was upset because a private room was not available. The Registered Nurse stated Patient #11's spouse came to the desk at the nurses' station and reported Patient #6 had cursed him/her after the spouse asked Patient #6 to move a bedside table. Registered Nurse #3 stated she called the House Supervisor to come and resolve the complaint voiced by Patient #11's spouse. The interview also revealed Certified Nursing Assistant #2 reported to RN #3 that Patient #6 had reported to the CNA that the spouse of Patient #11 pushed a bedside table into Patient #6 and had almost knocked the patient down. The Registered Nurse stated she did not inform the House Supervisor of the allegation Patient #6 made because the Registered Nurse felt the incident had been resolved when Patient #11 was moved to a private room.

Interview conducted on 12/15/11, at 6:15 PM, with the House Supervisor revealed on the evening shift on 12/01/11, a nurse called her to report a conflict with Patient #11's spouse. The House Supervisor spoke with the patient's spouse and was informed Patient #6 had moved a bedside table to the middle of the room and refused to move it back. The interview revealed the conflict was resolved when Patient #11 was moved to another room. The House Supervisor did not interview Patient #6 and stated "if it was against an employee or abusive" then it would have been documented and reported. According to the House Supervisor, if two patients did not like each other, the facility would not conduct and investigation but try to resolve and defuse the incident. The House Supervisor also stated she was unaware of Patient #6's allegation.

Interview conducted on 12/15/11, at 7:00 PM, with the Chief Nursing Officer (CNO), revealed the allegation was reported to her by the family member of Patient #6 three days after Patient #6 had been discharged from the facility. According to the CNO, the Patient Service Representative and the Unit Manager had interviewed staff and no one knew about the incident. The CNO stated based on information that had been obtained, it had been determined there was not a threat because both patients that had reportedly been involved in the incident had been discharged from the facility.