HospitalInspections.org

Based on record review and interview, the facility failed to have documentation of evidence that a thorough investigation had been completed for an injury of unknown origin for 1(#1); an elopement with injuries for 1(#2); and failed to meet the reporting requirements of 24 hours for the initial report, and report the results of the investigation within five working days for two (#s 1 and 2) of five sampled patients. Findings include:

Review of a facility reported incident for patient #1 included a cover page that showed it was faxed to the State on 4/17/2020. The incident report form showed the incident occurred on 3/19/2020, and was submitted by staff member B. The form showed patient #1's name as the patient and allegation type was abuse. The area on the form that required the summary of the incident was blank. Documented under the heading "Notifications" was marked "No" for law enforcement and "Yes" for state ombudsman. Stapled to the form was an untitled and undated paper showed, "3/19/2020-RN [initials] reported to this staff about suspicious bruising to resident [omit] on upper inside left arm, approximately the size of a fist. This patient complained of pain to the left arm when staff tried repositioning that arm..."; "an x-ray showed a 'mildly compressed fracture of the surgical neck of the humerus'... "3/23/2020- After review of the chart and visiting with nursing staff regarding this patient, no abuse was found at this time. When asked if anyone had hurt him [patient's initials], stated no." Requests for all documentation to show the investigation process, staff interviews and written statements, interventions put into place to protect the patient, corrective actions, notifications to the patient's representative, and administrator review was requested on 1/20/2021 at 11:17 a.m., 12:01 p.m., and 1:10 p.m. No information was submitted to show a thorough investigation had been completed.

Review of a list without a date or identifying information of the composer, submitted by staff member B, on 1/20/2021 at 10:15 a.m., showed patient falls with injury and included two patients. One of the patient's on the list was patient #2. Review of patient #2's nurse's note, dated 12/13/2020 at 1:40 p.m., showed, "Called outside by a staff's family, resident had gotten outside and slipped on the ice. initial assessment noted an abrasion to his right cheek and the back of his right hand. Some scuffing seen on the back of his right shoulder. Resident shaking and cold, assisted up to a wheelchair via CNA and kitchen staff that assisted and covered with a couple tablecloths and brought back into the facility. Resident given a warm blanket and pressure applied to abrasions on face and hand."

During an interview on 1/20/2021 at 3:24 p.m., staff member B stated no incident report was completed for patient #2's elopement from the facility on 12/13/2020. Staff member B stated the elopement and fall was not reported to her, and she did not follow up to see if an incident had been made. Staff member B stated for elopements there was normally an incident report completed with an investigation. Staff member B stated there was no documentation to show family had been notified. Staff member B stated the facility should have had and incident report done for that incident. No documentation was submitted to show notification was made to the appropriate agencies within twenty-four hours, and a follow-up of the investigation results within five days.

During an interview on 1/20/2021 at 8:47 a.m., staff member D stated if abuse or neglect was suspected for a patient a report was filed. Staff member D stated the charge nurse does the paper work for what happened, and the patient would be asked questions if they were able to let staff know.

During an interview on 1/20/2021 at 9:07, staff member E stated if a patient is being abused or neglected, first get the patient safe. Staff member E stated a report is filled out and sent to the State. Staff member E stated the facility social worker reports to the State and family. Staff member E stated there would be an investigation done by the director of nursing and the social worker. Staff member E stated the information had to be written on the report i.e.: the cause, facts of the incident, and how to prevent. Staff member B stated the report gets sent to the State.

During an interview on 1/20/2021 at 3:52 p.m., staff member C stated she was "not sure where incident reports go" at the facility. Staff member C stated she was not sure how allegations of abuse or neglect were documented or reported. Staff member C stated she was notified by nursing staff of the bruising to the left arm for patient #1. Staff member C stated she did order a pain medication, lab work and x-ray of the left arm. Staff member C stated she was surprised that patient #1's arm was fractured. Staff member C stated she did not "see any documentation in patient #1's medical record explaining how the injury occurred." Staff member C stated, "abuse did not come to the forefront of my mind." Staff member C stated she was notified of the elopement for patient #2. Staff member C stated she was told by the nursing staff that they had placed a Wanderguard on patient #2. Staff member C stated she had never signed or been a part of the process for reviewing allegations of abuse or neglect at the facility.

During an interview on 1/20/2021 at 4:34 p.m., staff member B stated, "If someone reports abuse or neglect I go to the State site and open a report. I get a statement and names of who is involved if any alleged harm, alleged abuser is asked to leave until an investigation is done. I get statements from witnesses, talk to nursing staff to ensure family was notified and the patient is safe. I document the alleged abuse or neglect on the state form and submit. I document the investigation on a word document. [patient #2's name] elopement should have been an incident report and documented on our in-house document the RL6. The administrator, director of nursing, and I review the incidents. We do not have it for the sample patients you are asking for documentation. Documentation is missing. I do not know how or why. We obviously need to figure that part out."

Review of the facility policy and procedure titled Abuse Prevention and Reporting, with a review date of 1/22/2019, included an Abuse Reporting Form under Appendix B. The form required the individual to complete a detailed report that included the patient's name, name of person reporting, the type of abuse, the date of the incident, the names of persons involved to include witness(es) and attach their written statement, who the accused individual was, a summary of the incident with pertinent dates and times, what immediate actions were taken to protect the patient, and who it was reported to. The facility did not submit evidence that the Abuse Reporting Form was completed for sampled patients #1 and #2 for the above incidents.