HospitalInspections.org

A.
Based on record review and interview the facility failed to ensure that the Governing Body assumed responsibility for the quality of care provided to the patients. Specifically, the Governing Body failed to ensure that an immediate and thorough investigation was conducted regarding an allegation of sexual abuse.

Findings:

On 9/29/14 Patient #1 made a verbal complaint that she was sexually abused by a staff member to several staff members. On 11/18/14 the facility received a written complaint from the patient regarding the sexual abuse allegation.

During an interview with Staff #10 on 12/08/14 at 1:00PM, the staff member stated she received the written complaint on 11/18/14. She e-mailed the Executive Director of Quality Management her plan to notify the Unit Nurse Manager, Senior Administrative Director and the Director of Social Work and she included a copy of the written Complaint. The Executive Director of Quality Management called her immediately.

Review of the e-mail from Staff #10 to Staff #7, dated 11/18/14 at 4:06PM, documented her plan to notify the Unit Nurse Manager, Senior Administrative Director and the Director of Social Work and she included a copy of the written Complaint and the Abuse Policy.

During an interview with Staff #7 on 12/04/14 at 11:25AM, the staff member stated she received the written complaint on 11/18/14 and took immediate action. She stated she e-mailed the Chief Nursing Officer and the Deputy Director Executive.

Review of the e-mail from Staff #7 to the Chief Nursing Officer and the Deputy Director Executive dated 11/18/14 at 4:46PM revealed the e-mail from Staff #10 was forwarded to them with the attachments and documented as "FYI-Nursing to investigate".

Review of the e-mails dated 11/21/14 timed 6:30PM and 6:48PM between Staff Members #15 and #10, and carbon copied (cc'd) to the Chief Nursing Officer and Executive Director of Quality, documented that the accused staff member had not been interviewed and would not be interviewed until the following week "so we can investigate further". The e-mail also indicated that the Nurse Manager "will be interviewing all staff involved in the patient's care".

Although the Executive Officers were notified on 11/18/14 of the allegation of patient abuse which occurred on 09/29/14, they did not ensure that an immediate and thorough investigation of the allegation was conducted and that appropriate action was taken to immediately remove the accused staff member from patient care during the investigation.
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Based on record review and interview it was determined that the facility did not comply with the Condition of Participation for Patient Rights. This was evident by the facility's failure to maintain an effective alarm system for the protection of the infants, to obtain physician's orders for the use of restriants, and to effectively implement the facility's abuse policy following a patient's allegation of sexual abuse.

Findings:

The facility failed to ensure a safe environment for infants. Specifically, the facility failed to ensure that: a) a properly working alarm system was in place for the protection of infants, and b) all of the Exit Doors on the Unit alarmed when in lock mode in order to minimize the potential risk for harm or abduction of infants.
(See Tag A 144)

The facility failed to protect patients from potential abuse and neglect, to investigate allegations of abuse and neglect, and educate staff regarding the facility's "Abuse and Neglect / Mistreatment of Patient" Policy.
(See Tag A 145)

The facility failed to ensure that there was a Physician's Order written for a patient who needed to be in Restraints and that the physician ordered the correct restraint based on the patient's needs.
(See Tag A 168)
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Based on observation, staff interview and demonstration, it was determined the facility failed to ensure a safe environment for infants. Specifically, the facility failed to ensure that: a) a properly working alarm system was in place for the protection of infants, and b) all of the Exit Doors on the Unit alarmed when in lock mode in order to minimize the potential risk for harm or abduction of infants.

Findings:

a) During the tour of the 5 and 6 Tower Maternity Units on 12/04/14 at 11:40AM, Staff #11 stated that an electronic tag system is used to augment safety and tracking of newborn infants on the Units.

An interview with Staff Members #11 and #12 on 12/04/14 at 11:40AM revealed that anyone who arrives to the Unit must be buzzed in by staff and that staff verify which patient they are going to visit.

All other doors are locked and cannot be opened without a swipe card, with the exception of the four (4) Stairwell Doors (one {1} on each end of the hallway on both 5 Tower and 6 Tower Floors) that only lock when an active infant monitor is within range of these Exit Doors.

During observation on 12/04/14 at 11:40 AM it was noted that these Units are accessed via employee swipe cards only but the Exit Doors are unlocked for anyone who tries to depart the Unit.

On 12/04/14 at 11:45AM, interview with Staff #11 revealed that this system operates using an electronic transponder band placed around the ankle of the infants which are connected to the monitoring system. The band alarms when it is cut or when the clasps are opened.

Demonstration and inspection of the facility's electronic infant security system was conducted on both of the Maternity Units located on 5 and 6 Towers respectively on 12/04/14 between 11:00AM and 3:00PM. One (1) Surveyor and three (3) facility staff were present during these testing sessions (Staff Members #10, #11 and #12).

The first simulation test inspection was conducted on 5 Tower on 12/04/14 at 11:45AM. Staff #12 wore the monitor bracelet over two (2) fingers during which it was observed that the auditory alarm sounded when the band was cut and when the clasps were open. However, the alarm failed to activate when the monitor was slipped off the fingers with the band and clasps intact. No visual alert on the computer tracking screen or audible alarm was noted, even after a waiting period of over two (2) minutes.

The band was readjusted, placement and activation were verified via the computer monitoring system, and the test was repeated. Again, no audible alarm or computer notification was observed.

A third simulation test was then performed on 6 Tower on 12/04/14 at approximately 1:40PM. Staff #12 wore the monitor bracelet over two (2) fingers during which it was observed that the auditory alarm sounded when the band was cut and when the clasps were open. However, the alarm failed to activate when the monitor was slipped off the fingers with the band and clasps intact. No visual alert on the computer tracking screen or audible alarm was noted, even after a waiting period of over two (2) minutes.

The tests performed found that the system failed to activate the alarms when the band was slipped off.

This was confirmed in the presence of Staff #10.

On 12/04/14 at 12:05PM during interview Staff #11 stated "We know that it works when the band is cut and the clasps are open, but we never thought to test it by slipping it off".

Staff #11 also stated "Security runs quarterly Drills to ensure the safety of our infants". Further interview, however, revealed that these Drills only test the "Infant Abduction" process, and do not test the system itself.

When asked if the Units regularly tested the infant alarm system, Staff #11 replied "Before we put the monitors on the babies, we check them to see if they are 'active and audible', but we do not test to see if the system is working by slipping off the monitors".

Review of the Infant Alarm System Manual titled "Safe Place Security Systems" did not reveal whether or not the system alarmed when the band slipped off the patient and the band was not cut and the clasps were not opened.

Staff #11 contacted the RF Technologies Representative on 12/04/14 during the testing and confirmed that the system is supposed to alarm when the monitor is slipped off of the infant, not just when the band is cut or the clasps are opened.

On 12/04/14 at approximately 3:00PM the facility placed Security Personnel at each of the four (4) Stairwell Exits with an "around the clock schedule" until the Alarm Company Representative arrived on 12/04/14 at 4:30PM and fixed the system.

b) The electronic monitoring device is linked electronically to a computer tracking system which activates a lockdown of a door when the infant wearing the device approaches within approximately three to four (3-4) feet of that door. There are two (2) components of the locking system: the first involves automatically locking the Exit Door from the Unit when a tagged infant is located close in proximity to the Exit Doors, and the second is an audible alarm component that sounds when a door is in lock mode and someone tries to exit through the door.

This system applies to all Entrance / Exit Doors on both the 5 Tower and 6 Tower Units, including the stairwells located at the end of each hallway, which exit directly to the street.

On 12/04/14 at 1:40 PM during the testing of the infant monitors, it was noted that the "A" Stairwell Door on 6 Tower Unit locked when approached by Staff #12 wearing the monitor bracelet over two (2) fingers, but the door did not alarm when an attempt was made to exit the door after it locked.

This was confirmed in the presence of Staff #10.
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Based on record review and interview it was determined that the facility failed to protect patients from potential abuse and neglect, to investigate allegations of abuse and neglect, and educate staff regarding the facility's "Abuse and Neglect / Mistreatment of Patient" Policy. This was evident when a patient complained of being abused by a staff member and the staff failed to implement the facility's Policy (Patient #1).

Findings:

Review of the Memorandum to Quality Management, initiated on 11/19/14, revealed that on 09/29/14 when Patient #1 complained that Staff #1 sexually abused her (touched her inappropriately), and three (3) Nurses, Staff Members #3, #5 and #6, were made aware of the allegation at that time, the facility's "Abuse and Neglect / Mistreatment of Patient" Policy was not immediately implemented.

The allegation was not investigated at the time of the occurrence. Staff #1 was not removed from patient access. A thorough investigation of the complaint allegation was not initiated and Staff #1 was not removed from patient access until the DOH's onsite visit on 12/04/14, approximately two (2) months after the patient's initial complaint.

The Memo further revealed that on 11/18/14, one and one-half (1½) months later, the facility received a written complaint from Patient #1 alleging sexual abuse by Staff #1.

Although Executive Management were notified of the allegation, once again the facility's "Abuse and Neglect / Mistreatment of Patient" Policy was not immediately implemented. An immediate investigation of the allegation was not implemented and Staff #1 was not removed from patient access and continued to work.

During an interview with Staff #2 on 12/05/14 at 12:00PM, Staff #2 stated that on 11/21/14, after learning of Patient #1's allegation during a post-operative office visit, he contacted the facility to relay the patient's complaint and obtain direction. Staff #2 stated that Patient #1 stated she had some type of sexual encounter during her hospitalization; that she was raped. A female staff member placed her fingers in her vagina and may have penetrated her. I spoke with the Quality Management Department and I was instructed to have the patient contact the Department. I gave the patient the contact's name and telephone number.

Once again, the immediacy of the investigation was not realized and Staff #1 continued to provide patient care.

The Memo revealed that on 11/25/14 a meeting with Staff #1, Unit Management, Human Resources and a Union Delegate was held to discuss the complaint allegation approximately two (2) months after the initial allegation.

Review of the Policy titled "Abuse and Neglect / Mistreatment of Patient" dated 11/25/14, documented that when a patient is suspected of being a possible victim of abuse, neglect or mistreatment, a full investigation of the incident will be done by the facility immediately. The Attending Physician, Supervisor / Nurse Manager, Social Work Department and Quality Management will be notified of the allegation. If an employee of the Health System is suspected of abuse, neglect, or mistreatment of a patient, the chain of command must be informed as well as Human Resources.

Review of 9 Tower's Staffing Schedules from 09/29/14 - 11/29/14 revealed that Staff #1 continued to work and was not removed from patient access, although on 09/29/14 Patient #1 accused Staff #1 of abuse and the formal documented interview with Staff #1 did not take place until 11/25/14.

An interview with Staff #1 on 12/05/14 at 10:25AM revealed that on 09/29/14 between 5:00AM and 6:00AM, when Staff Members #1 and #3 changed Patient #1's incontinence pad, Patient #1 accused Staff #1 of "touching her private parts". Staff #1 notified the Unit Managers, Staff Members #5 and #6 of the accusation.

An interview with Staff #3 on 12/05/14 at 11:00AM revealed that on 09/29/14 at 12:15AM Staff #1 came out of Patient #1's room crying and shaking. Staff #1 stated Patient #1 told her she "would get her for what she did". Staff #1 denied doing anything to Patient #1. Staff #3 instructed Staff #1 not to go into Patient #1's room anymore unless they were together. Between 5:00AM and 6:00AM when Staff Members #1 and #3 turned Patient #1 toward Staff #1, Patient #1 stated "I know what you did. I'm going to get you". When Staff #3 asked Patient #1 what did Staff #1 do? Patient #1 stated "she touched my vagina". I told Staff #1 to get the Charge Nurse. Staff #3 explained to Patient #1 that I have been with Staff #1 since midnight, you have never been alone Staff #1. She could not have done that.

Although Staff #3 observed Staff #1, the accused employee, leaving Patient #1's room earlier that shift, when Patient #1 accused Staff #1 of touch her inappropriately, Staff #3 incorrectly told the patient she was never alone with this patient and that "It could not have happened".

An interview with Staff #5 on 12/08/14 at 10:00AM revealed that when she went to Patient #1's room to discuss the allegation, Patient #1 stated "I don't want to discuss it. I don't want her to lose her job". Staff #5 told Patient #1 that she respects her wishes not to discuss the incident and told her the Nurse Manager would be in the morning and let her know if you change your mind.

During an interview with Staff #7 on 12/04/14 at 11:25AM she stated that when the patient complained of being abused by Staff #1 on 09/29/14, the staff did not follow the facility's Policy. The Quality Assurance Department was not notified of the allegation. On 11/18/14 the Quality Assurance Department received a written complaint from Patient #1 regarding being inappropriately touched by a staff member during her hospitalization. Immediate action was taken. Hospital Administration, Staff Members #13 and #14, were notified of the allegation. The patient was called for more information. An investigation was implemented. Staff #15 was instructed to immediately do an investigation. She stated that based on a past informal, incomplete investigation that was done when the patient initially complained, they felt they did not need to remove the accused staff member from patient care.

During an interview with Staff #6 on 12/08/14 at 10:40AM the staff member stated that Staff #1 came to my office on 09/29/14 in the morning crying and stated that Patient #1 accused her of touching her private parts. I told Staff #1 to go home. I briefed the staff about the allegation and instructed them to take a coworker into the patient's room when they care for her. I interviewed the patient who said everything was good. I did not asked her about the allegation. I did not write anything up at that time. When the written complaint came in, Staff #15 called me to their office on 11/18/14 or 11/19/14. We discussed the allegation and I was told I should have escalated the complaint to her. I was instructed to complete an investigation and re-interview Staff #1, the accused staff member, with Human Resources.

During an interview with Staff #15 on 12/08/14 at 11:45AM the staff member stated that we did not treat it as an abuse allegation and remove the Personal Care Aide (PCA), Staff #1, from work because the patient was described as hallucinating and she was not receiving her psychiatric medications. The medications needed to be readjusted. I did not have a reason to be overly concerned due to the PCA's (Staff #1's) reputation. If I had felt the allegation was true I would have removed the PCA (Staff #1) immediately from patient care.
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Based on record review and interview, the facility failed to ensure that: a) there was a Physician's Order written for a patient who needed to be in restraints in two (2) of five (5) records reviewed (Patients #6 and #11), and b) the physician ordered the correct restraint based on the patient's needs in one (1) of five (5) records reviewed (Patient #9).

Findings:

a) Patient #11 is a 22-year-old male who lives locally at a Group Home Residence. Upon admission to the Emergency Department (ED) the patient was described as being agitated and was combative on 12/01/14 at 1:45PM. The patient was awake, alert and irritable. The patient was documented as disoriented.

The staff from the Group Residence, who accompanied the patient, stated he is always combative and is unable to be de-escalated. The patient was documented to be to this Emergency Department (ED) numerous times in the last two (2) days. The patient attempted to spit on staff and bite staff on arrival to the Behavioral Health ED.

A Physician wrote an Order for a Violent Self-Destructive Level Two (2) Restraint on 12/01/14 at 2:16PM with an Order duration of two (2) hours. The type of Restraint ordered was Four (4) Point.

It was documented in the Order that the Restraint was to be "auto-discontinued on 12/01/14 at 4:15PM".

Review of the Quality Management Nursing Restraint Log documents that the patient remained in Four (4) Point Restraints from 12/01/14 at 1:30PM until 12/01/14 at 5:30PM for a total of four (4) hours. The documented reason was "Combative". The form states "Yes" under the heading "MD Order".

The facility's Policy titled "Restraints" documents that the use of Physical Restraints requires written authorization of the Physician / LIP (Licensed Independent Practitioner) or his or her Licensed Independent Practitioner Designee. The Order may not exceed four (4) hours for an adult. The Physician or LIP has the discretion to write the Order for a shorter period of time.

There is no evidence in the Medical Record that the Physician / LIP wrote for the additional two (2) hours that the patient was in the Four (4) Point Restraints.

This was discussed and confirmed with Staff #8 on 12/02/14 at 11:30AM and again reviewed with Staff #9 on 12/05/14 at 10:00AM.

Patient #6 was admitted to the facility on 11/29/14 with diagnoses of Right Lower Lobe Pneumonia and Sepsis. The patient required placement of a Nasogastric Tube (NGT).

Review of the Medical Record revealed that an Order was placed for "Bilateral Wrist Restraints" x four (4) hours on 12/01/14 at 9:25PM for medical management, due to the patient attempting to pull out the NGT. The automatic Order "Stop" was documented at 2:30AM on 12/02/14.

The Re-Order for Bilateral Wrist Restraints was placed on 12/03/14 at 8:26AM x four (4) hours and was discontinued on 12/03/14 at 11:08AM. The Restraint was then re-ordered on 12/03/14 at 11:26AM x twenty-four (24) hours.

Additional Medical Record review revealed that the Nursing Staff consistently documented that the patient remained in Bilateral Wrist Restraints from 12/02/14 at 2:30AM through 12/03/14 at 8:36AM. No Physician's Order was noted for those documented thirty (30) hours.

During review of the Medical Record with Staff #16 in the presence of Staff Members #15 and #10, the staff acknowledged the lack of Medical Orders for the thirty (30) hours.

b) Patient #9 was admitted to the facility on 11/26/14, with a diagnosis of Cerebral Vascular Accent with Right Hemiparesis. The patient required the use of a NGT for medications and feeding.

Review of the Medical Record revealed an Order was placed for "Bilateral Wrist Restraints" x twenty-four (24) hours on 11/28/14 at 5:06PM for medical management, due to the patient attempting to pull out the NGT.

On 11/28/14 at 5:10PM, a second Order was placed for "Bilateral Wrist and Bilateral Ankle Restraints" x twenty-four (24) hours for medical management.

Nursing documentation in the patient's Flow Sheet, however, documents a "Left Wrist Restraint" in place.

During observation of the patient on the afternoon of 12/05/14, the patient's right arm and hand appeared to be contracted and the patient was unable to move it independently. Both Restraint Orders did not reflect the physical needs of the patient.

This was confirmed with Staff #17 at the time of observation in the presence of Staff #18.
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Based on record review and interview it was determined that the facility failed to assess patient safety and the quality of care rendered to a patient involved in a complaint and to implement appropriate / timely corrective measures to prevent a reoccurrence (Patient #1).

Findings:

The Memo titled "Review of Policy #100.14 and Coaching Session" dated 11/19/14 was reviewed on 12/04/14. The Memo included documentation that on 09/29/14 Staff #1 notified Staff #6 that Patient #1 accused her of inappropriate behavior. The requirements that the incident should have been immediately investigated, escalated to the Senior Administrative Director and reported to the Quality Assurance Department and the Social Work Department were reviewed with Staff #6.

On 11/19/14 only Staff #6 received education regarding the "Abuse and Neglect / Mistreatment of Patient" Policy. There was no documented evidence that Staff Members #3 and #5 received the education.

During an interview with Staff #7 on 12/04/14 at 1:25PM the staff member stated that only Staff #6 was educated on 11/19/14 regarding implementing the facility's Policy for abuse. The other two (2) Nurses, Staff Members #3 and #5 who were aware of the allegation, did not receive education because they escalated the allegation to their Supervisor.

Review of the document identified as "Plan of Correction (POC) RE: Abuse Complaint Not Escalated on September 29, 2014" presented to the surveyor on 12/04/14 , documented all Nursing Staff will be educated on the Abuse Policy and Complaint Process by 02/28/15.

During an interview with Staff #7 on 12/04/14 at 1:25PM the surveyor asked when the POC had been developed, the staff member stated that the POC was written today, 12/04/14.

A systemic Corrective Action Plan was not documented until 12/04/14, the date of the DOH's onsite visit and at least two (2) months from the date of Patient #1's initial complaint. Also, the Corrective Action Plan had a completion date of 02/28/15, which failed to immediately address the staff's lack of knowledge regarding the facility's "Abuse and Neglect / Mistreatment of Patient" Policy.

Review of the Personnel Files for Staff Members #3, #5 and #6 revealed that the staff members received education regarding Abuse, Neglect and Mistreatment of Patients in 2014. However, the education did not include an education of the facility's Policy titled "Abuse and Neglect / Mistreatment of Patient". The facility's investigation did not identify this as a problem and as a result corrective measures were not implemented.

Review of the Policy titled "Abuse and Neglect / Mistreatment of Patient" revealed that the Policy did not include the immediate removal of the accused staff member from patient access. The facility's investigation did not identify this as a problem and as a result corrective measures were not implemented.

Review of the Memorandum initiated on 11/19/14, and the staff statements dated 11/20/14 and 11/25/14, revealed not all of the staff involved in the patient's care on the date of the alleged incident were interviewed. Also, there was no documented evidence of a written statement from Staff #1, the accused.

During an interview with Staff #7 on 12/04/14 at 1:25PM the staff member confirmed this finding.

See Tag A 145

Based on record review and interview, the facility failed to ensure that the physician ordered Patient #1's post operative medications timely.

Findings:

Review of Patient #1's Record revealed that on 09/25/14 the patient had a Right Total Knee Replacement and was extubated 09/26/14.

Review of Patient #1's "Home Medications" Form documented the patient took Klonopin 1 mg orally two (2) times a day and Citalopram 10 mg every day.

Review of the Physician's Orders dated 09/29/14 documented that Klonopin 1 mg orally two (2) times a day and Citalopram 40 mg every day were ordered and the Record documented that the medications were administered following the Order.

The patient's medications were not ordered or administered until three (3) days after she was extubated.

During an interview with Staff #7 on 12/08/14 at 11:00 AM, the staff member stated that the patient was alert and she did not have any change in condition that would prevent her other medications on hold to be considered. Staff #7 also stated that they did not reevaluate her medications. She agreed there was a delay in implementing the patient's Klonopin and Citalopram after she was extubated following surgery.

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Based on record review, observation and interview, the facility failed to ensure that the Nursing Staff communicated and confirmed with the Physicians, the patient's specific need for restraints in one (1) out of five (5) records reviewed (Patient #9).

Findings:

Patient #9 was admitted to the facility on 11/26/14 with a diagnosis of Cerebral Vascular Accent and had Right Side Paralysis. The patient required the use of a Nasogastric Tube (NGT) for medications and feeding.

Review of the Medical Record revealed an Order was placed for "Bilateral Wrist Restraints" x twenty-four (24) hours on 11/28/14 at 5:06PM for medical management, due to the patient attempting to pull out the NGT.

Four (4) minutes later, on 11/28/14 at 5:10PM, a second Order was placed for "Bilateral Wrist and Bilateral Ankle Restraints" x twenty-four (24) hours for medical management.

During observation of the patient in the afternoon of 12/05/14, the patient's right arm and hand appeared to be contracted and the patient was unable to move it independently. Both Restraint Orders did not reflect the physical needs of the patient.

Review of the Nursing Care Plan and documentation in the patient's Flow Sheet noted a "Left Wrist Restraint" in place. Due to the right side paralysis, the Left Wrist Restraint was appropriate for the patient, yet the Care Plan did not reflect communication among the Physicians and Nurses to ensure that the Restraint ordered met the patient's needs.

This finding was confirmed with Staff #17 at the time of the Medical Record review, in the presence of Staff #18. Staff #17 stated she should have confirmed the Order with the Physician.
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