HospitalInspections.org

Based on interview and document review, the facility failed to investigate and implement a policy that protected patients including 1 (#16) of 5 patients reviewed for abuse, from an alleged abuser, resulting in the potential for unsatisfactory outcomes for any of the 81 patients currently being served by the facility. Findings include:

(See A-145)

Based on interview and document review, the facility failed to investigate and implement a policy and procedure that protected patient (#16) from an alleged abuser, out of five patients reviewed for abuse, resulting in the potential for unsatisfactory outcomes for any of the 81 patients being served by the facility. Findings include:

On 4/21/2022 at 1220, an interview was conducted with Shift lead Registered Nurse (RN) Staff Q. During the interview it was revealed that patient #16 had reported that RN Staff Y had "inappropriately touched her breast." Staff Q said she reported the concern to the House Supervisor (Staff R), who came up to speak with the patient. Staff Q said she switched Staff Y's assignment. Staff Q said she told her manager in the morning. Staff Q said she did not recall the patient's name. She said the patient was no longer a patient. Staff Q said it happened a couple of weeks ago on the 5th floor. Staff Q was asked if she documented an incident/accident report and she replied she had not.

An interview was conducted with Nurse Manager Staff G on 4/21/2022 at 1345 regarding the allegation of abuse pertaining to patient #16. Staff G confirmed that Staff Q had informed her of the abuse allegation concerning patient #16 on the following morning. Staff G was asked if she spoke to the patient (#16) concerning the allegation, she said she did not. Staff G was asked if she spoke to Staff Y concerning the allegation, she said she did not. Staff G was asked if she spoke to Staff R concerning the allegation, she said she did not. Staff G was asked if she had received any emails from Staff R regarding the incident, she replied, I looked there is nothing. Staff G was asked if she conducted an investigation or if she filed an incident report, she said she did not. She explained, "I probably should have."

On 4/21/2022 at 1445, review of the medical record for patient #16 revealed the following:
Patient #16 was a 63-year-old female who was admitted to the hospital on 4/7/2022 with a primary diagnosis of pneumonia. The patient was discharged on 4/14/2022 to a local nursing facility.

Review of the facility's "Safety Event Reporting" policy with an effective date of 1/14/2022 documented the following:

I. PURPOSE AND OBJECTIVE:
Continuous improvement of patient safety is our guiding principle in achieving quality and reducing morbidity and mortality.
Reported occurrences will be, analyzed, trended and utilized through review processes to continually improve systems, processes, education and training to reduce/avoid their occurrence. The focus will be on the causes that underlie the event, and on making changes in the organization's systems and processes to reduce the probability of such an event in the future.

II. POLICY STATEMENT:
All employees and practitioners are responsible for fully cooperating in efforts to improve patient safety, reduce risks and minimize occurrences. This includes the reporting of occurrences that result in actual or potential injury to a patient. Reporting may include communication of the event to the employee manager, to the corporate compliance line, and/or documenting in the RL Solutions automated system upon discovery of the event.


Review of the facility's "Suspicion of Vulnerable Adult and Elder Abuse" policy with an effective date of 10/8/2021 documented the following:

I. PURPOSE AND OBJECTIVE:
To provide guidance and objective criteria for identification, assessment, care, reporting and referral of patients who are possible victims of alleged or suspected abuse, neglect or exploitation. Abuse and Neglect includes abuse of neglect of elders and vulnerable adults- including sexual assault and physical assault. Exploitation includes taking unjust advantage of another for one ' s own advantage or benefit.
II. POLICY STATEMENT:
It is the policy of Beaumont Health that Vulnerable adults and the Elderly will be assessed for possible abuse, neglect and/or exploitation. If there is reason to believe that abuse or neglect may have occurred, appropriate diagnostic care and care procedures, internal and external resources, and reporting procedures are implemented to coordinate the care and protection of the suspected victim...
IV. PROCEDURE:
A. Assessment:
"1. All patients treated in any clinical setting will be assessed for the possibility of exposure to
abuse, neglect or exploitation.
2. Assessments of adults suspected of being victims of abuse/neglect/exploitation should
include objective documentation of the following parameters:
a. Physical appearance of the patient.
b. History provided by the patient, family and/or caregiver. This includes history provided by
the facility from where patient came if appropriate.
c. Assessment of whether the history and/or physical examination are consistent with the
injury or illness.
d. Activity and behaviors of the patient.
e. Verbatim statements made by the patient, family and/or caregiver.
f. Interaction between patient and family/caregiver.
g. Care giver ' s perceptions and expectations about the patient.

B. Interventions and Documentation: The following interventions shall be performed and documented
in all cases of suspected vulnerable elder abuse/neglect/exploitation:
1. If the patient has concerns about their immediate safety, consider offering the patient an
alias. Refer to policy Alias/Privacy Status Request
2. Health Care Provider (HCP) notifies the physician responsible for the patient ' s care of suspected abuse, neglect or exploitation if HCP not aware.
3. Physician performs history and physical examination including clear description and
documentation of any injuries.
4. Physician orders x-rays, laboratory studies and other studies or consultations as indicated.
Consider a request for a Geriatric Medicine consultation for elderly patients in whom abuse or
neglect is suspected.
5. HCP obtains photographs when indicated.
6. HCP provides non-judgmental emotional support:
a. Encourage patient, family or caregiver to verbalize feelings and provide history/
psychosocial data.
b. Validate patient ' s experiences and affirm patient ' s right to safety.
7. HCP offers patient/family resource materials and information if appropriate.
8. HCP notifies patient or if patient is incapacitated the patient ' s legal guardian, patient advocate or closest next of kin of the findings, diagnosis, disposition, and the mandate to report the case to the appropriate State Agency and/or Police..."
However, that was not done.

Based on interview and record review, the facility failed to develop and implement policy/procedure for additional precautions for all non-immunized COVID-19 health care exempt staff that included 6 out of 6 Staff (S, T, U, V, W, and X), that were not vaccinated for COVID-19 infection, resulting in the potential for the transmission and spread of COVID-19 infections for all 81 patients being served by the facility. Findings include:

On 4/20/2022 at 0930, during an interview Chief Nurse Officer (Staff A) was queried regarding their policy/procedure for Health Care Staff Vaccination for COVID-19 immunization. On 4/20/2022 at 0935, Staff A replied, "It's mandatory for all staff unless they have medical or religious exemptions."

On 4/20/2022 at 1550, a review of unvaccinated employee exemptions records for Staff S, T, U, V, W and X) revealed the following:

Staff S was a Registered Nurse who was granted her request for medical exemption on 9/3/2021.
Staff T was a Registered Nurse who was granted her request for medical exemption on 8/16/2021.
Staff U was a CT technician who was granted her request for religious exemption on 3/25/2022.
Staff V was a Nurse Assistant who was granted his request for religious exemption on 8/4/2021.
Staff W was a student who was granted her request for medical exemption on 8/1/2021.
Staff X was a student who was granted her request for religious exemption on 12/14/2021.

Staff A was queried on 4/21/2022 at 1430, regarding their policy/procedure to determine if any additional precautions to mitigate the risk for the transmission of COVID-19 infections for non-vaccinated staff with medical or religious exemptions were required. Staff A was asked if weekly testing for COVID-19 was done or if those unvaccinated staff were required to a wear a N-95 mask. Staff A replied, no we don't do weekly testing, he said we only require the N-95 for staff who are providing care for patients with COVID or if they choose to wear respirators. He said we require screening for all staff and visitor who come into the building.

Review of the facility's "Mandatory COVID-19 Vaccine" policy dated last revised on 2/1/2022 documented the following:

II. Policy Statement:
"COVID-19 immunization is required for all Team Members...In addition to the vaccination requirements, all Team Members are expected to comply with all other safety requirements for COVID-19 based on guidance from the CDC and other applicable regulatory agencies that govern public health and safety..."

VI. Requests for Exemption:
"...D. Team Members who have an exemption granted as a valid medical or religious accommodation will be required to wear a mask in all (name of facility's) at all times and may be subject to periodic COVID-19 testing and other health and safety standards..."

Further review of the facility's policy revealed there were no additional precautions for staff who were non-immunized and granted exemptions from vaccination to mitigate the risk of the transmission of COVID-19 infections.