HospitalInspections.org

Based on interview and document review, the facility failed to develop and implement a policy that protected patients including patient #1 from an alleged abuser while an investigation was in progress, resulting in the potential for unsatisfactory outcomes for any of the 170 patients currently being served by the facility. Findings include:

(See A-145)

Based on interview and document review, the facility failed to develop and implement a policy that protected 1 (#1) of 1 patients from an alleged abuser while an investigation was in progress, resulting in the potential for unsatisfactory outcomes for any of the 170 patients residing in the facility. Findings include:

On 10/19/21 at approximately 1210, review of an Incident/Accident report for patient #1, dated 9/21/2021 at 1545 was conducted with Nurse Manager Staff C and revealed the following:

On 09/21/2021 at 1545, Registered Nurse (RN) Staff F documented she heard patient #1 hollering "Nurse! Help! Staff F documented "the patient said staff would not allow her to leave the room and also stated that the 1:1 staff had hit her in her right forearm. Staff F documented the patient's right forearm was noted with redness and discoloration and that she offered ice to the patient and applied to the patient's right forearm.

On 10/19/2021 at 1225, Staff C was queried regarding the incident involving Resident Care Aide (RCA) Staff G and patient #1. Staff C explained RCA Staff G was reassigned to a different unit following the incident with patient #1. Staff C said the investigation ongoing and was still open.

On 10/19/2021 at 1450, RN Staff F was interviewed via phone. Staff F confirmed she had observed the patient of concern (#1's) right forearm. She confirmed the patient's right forearm was observed with redness and discoloration. Staff F confirmed she had provided the patient with an ice pack. Staff F explained RCA Staff G was reassigned temporarily to another unit on the day following the incident.

On 10/19/2021 at 1525 RCA Staff G was interviewed on site. He explained he worked the afternoon shift and was currently working. According to Staff G, on 9/21/2021 the patient (#1) was on 1:1 staff to patient observation. He said he was assigned to patient #1 for a 4 hour time frame (1430 until 1830). He confirmed that on 9/21/2021 the patient (#1) had reported that he had hit her. Staff G said following the incident he was assigned to a different nursing unit. Staff G was queried regarding whether or not he had been counseled or suspended. He replied he had not. He said he was aware that the investigation was open. He said he reported to nursing unit R2 as instructed following the incident. He said he later left the facility and went to a local Urgent Care. Staff said he returned to work and submitted an incident report. He said she (#1) had injured him. Staff G said he was scheduled off work the following day but reported to work on his next scheduled work day (9/23/2021).

On 10/20/2021 at 1045, Staff C was asked to explain why RCA Staff G had not been suspended pending the investigation. Staff C said, "there was no evidence of injury noted to the patient." She stated, "I saw the patient, the psychiatrist saw the patient and the medical doctor assessed the patient for injury and there was none."

On 10/20/2021 at 1055, during an interview and review of the facility's abuse policy Hospital Director (Staff A) was queried regarding the facility's response to allegations of abuse that were documented on the I/A dated 9/21/2021 regarding patient (#1). At that time, she (Staff A) replied, "He (Staff G) should not have been working." She said, "We did not follow our policy for abuse."

A review of the facility's "Abuse and Neglect: Definitions and Reporting" policy dated, effective 8/16/2020 documented the following:
Standards:
Treatment, Reporting and Safeguarding Patients
" ...C. Staff accused of abuse/neglect may be relieved of duty and directed to leave the grounds until notified by the Human Resources Director/Designee to return to duty.
However, that was not done.