HospitalInspections.org

Based on facility policy, staff interviews, Video surveillance review, and a review of the facility ' s incident report logs, it was determined the facility failed to protect the rights of one patient (P#1) out of three (P#1, P#2, P#3) sampled by not thoroughly investigate an allegation of abuse and failing to suspend an employee alleged to have abused a patient until a thorough investigation was completed.

Cross-Reference A-0144 as it relates to the facility ' s failure to conduct a thorough investigation into the alleged abuse of P#1 jeopardizing P#1 right to care in a safe setting.

Based on facility policy, staff interviews, Video surveillance review, and a review of the facility ' s incident report logs, it was determined the facility failed to assure care in a safe setting for one patient (P#1) out of three (P#1, P#2, P#3) sampled, by not thoroughly investigate an allegation of abuse and failing to suspend an employee alleged to have abused a patient until a thorough investigation was completed.


Findings:

Review of the "Patient Abuse and Neglect" policy PR#11, reviewed 1/2022, revealed that any abuse or neglect alleged to have occurred at any time within the facility must have been investigated, regardless of the length of time between the alleged event and the initial report. Thorough investigations of allegations of abuse and neglect would be documented on "Confidential Incident Investigation" forms. The investigation would include but not be limited to timely review of medical record documentation, incident reports, written statements or interview narratives from all staff that were physically present in the vicinity of the alleged abuse victim at the time of the alleged action, as well as all staff that were assigned to work with the patient up until the time of the report. Once the facility administrator received a report of abuse/neglect, should the preliminary investigation warrant a full investigation, the alleged perpetrator may have been suspended until the investigation was completed.

A review of the "Incident Reports" policy, PI Risk 3, reviewed 1/2022, revealed that unusual incidents would be reported immediately to the supervisor of the staff member involved. The staff member who was involved or who witnessed the event would complete an incident report form prior to the end of the shift. The report would be forwarded to the Performance Improvement (PI) director and the Chief Nursing Officer (CNO) by the end of the shift. A report that an event happened to the patient with a description of the event with documentation identifying that the physician was informed, and any subsequent care needed would be documented.

Review of the facility Incident Log from 3/2022 revealed that there was an incident where P#1 threw a cup of water at a nurse. While P#1 was being taken to seclusion, two MHT's were walking directly behind P#1 and tripped on the patient's leg twice before stepping back.

Review of an incident report by MSW CC involving P#1 on 3/12/22 at 11:45 a.m. revealed that RN DD was preparing medications when P#1 threw a cup of water that hit RN DD. RN DD left the medication room and started to force P#1 into seclusion while kicking the patient in her bottom, jerking, and pushing. The incident report said the nurse was not in danger but responded inappropriately out of aggression. Review of the incident investigation revealed that camera footage was reviewed and there was contact between RN DD and P#1's legs two times that did not seem intentional.

An interview took place with the Chief Nursing Officer (CNO) AA on 4/6/22 at 2:25 p.m. CNO AA said his first day at the facility was 3/7/22. CNO AA said whenever an incident happened at the facility, the Risk Manager (RM) would be allowed to do an independent investigation. CNO AA said RM II reviewed the surveillance tape and said there was not a problem with the incident involving P#1. If the RM had said an investigation was needed, the staff member involved would have been suspended during the investigation. Once it was determined that there was an issue, the facility would have taken disciplinary action, including termination. An incident like the one reported on 3/12/22 would have resulted in termination, if substantiated. CNO AA said part of a thorough investigation would have included meeting with RN DD, the Risk Manager, and the supervisor of the unit to hear what RN DD had to say, to see if it matched up with what was seen on the video. Everyone who was present during the incident would be heard as witnesses. CNO AA said wherever there was a preponderance of evidence would probably be what happened.

An interview took place with the Director of Risk Management (RM) II on 4/6/22 at 4:37 p.m. in the Conference Room. RM II said she first became aware of the incident involving P#1 on 3/14/22 when the incident report was in her box. RM II said she pulled up the camera footage and watched the videos. RM II said she only watched the videos after the incident and did not save them on her computer. RM II said there was no timeframe on the policy about retaining videos and she did not download any video; RM II did not feel the video surveillance was warranted any further. RM II said video was usually saved when there was a question of abuse that looked substantiated. RM II said the investigation was closed and there was no further investigation after viewing the videos, because RM II did not see any inappropriate interaction, and RM II did not feel the video matched the incident report.

A review of video footage took place on 4/6/22 at 10:00 a.m. with the Director of Risk Management (RM) II in the Risk Management Office. Video footage from all camera views was requested by the surveyors. After viewing video surveillance from an overhead camera, RM II attempted to bring up other camera views. An error message "Playback Failed," appeared on the screen for each video attempted. RM II said she was able to view the footage previously where she saw RN DD walking close behind P#1 and physically "connecting" with P#1 for two strides. RM II further said she did not speak to the staff and there were no interviews concerning the incident with P#1 on 3/12/22.

Video footage at the 11:27:32 mark revealed an individual identified as MSW CC was standing in the hallway facing the nurses ' station observing the staff members escorting P#1 to the seclusion room.

11:27:59. RN DD was observed walking back toward the medication room. MSW CC continued to observe as P#1 was taken to the seclusion room.

The facility failed to ensure care in a safe setting for all patients admitted by not thoroughly investigating when MSW CC alleged to witnessed RN DD abuse P#1.

Based on interviews with the complainant and staff, and a review of medical records, and a review of policies and procedures, it was determined the facility failed to use a system of record maintenance that ensured the integrity and security of all record entries when one medical record (P#1) out of three (P#1, P#2, P#3) sampled was missing a clinical note detailing alleged abuse by RN DD.


Cross Reference A-0438 as it relates to the facility ' s failure to maintain the integrity of P#1 medical record when a note detailing alleged abuse was not available in the record at the time of survey.

Based on interviews with the complainant and staff, and a review of medical records, and a review of policies and procedures, it was determined the facility failed to use a system of record maintenance that ensured the integrity and security of all record entries when one medical record (P#1) out of three (P#1, P#2, P#3) sampled was missing a clinical note detailing alleged abuse by RN DD .


Findings

A telephone interview took place with the complainant on 4/4/22 at 12:17 p.m. The complainant said that a note by a social worker was observed in P#1's medical record that stated a staff member shoved and kicked P#1.

A telephone interview took place with the social worker (MSW) CC on 4/5/22 at 2:28 p.m. MSW CC stated she documented an incident involving P#1 on 3/12/22 in the medical record under Clinical Notes toward the back of the nurses' notes.

A review of P#1 ' s medical record was completed on 4/7/22. A query was asked of RM II if the record was noted to be true and complete. RM II confirmed the medical record was completed.

Review of a Clinical Note, Social Services Note, that was emailed by the complainant, revealed a hand-written note on facility letter-head with a patient label identifying P#1. The note was dated 3/12/22. The contents of the note were as follows:

"Therapist contacted mom to inform her patient had received meds in effort to calm her down. Patient was then sent to seclusion. While getting patient to calm down a code was called for further assistance. As patient was getting ready to receive meds by the med room, patient threw a cup of water at (RN DD). Techs walked patient toward seclusion and (RN DD) unlocked the med room and started to shove patient and repeatedly kick patient in the bottom with his knee."

The note was signed by MSW CC.

A Teams virtual interview took place on 4/6/22 at 4:30 p.m. with MSW CC. MSW CC was able to view a Clinical Note on screen sharing that was dated 3/12/22. MSW CC verified that the note was in her own handwriting and the content matched what MSW CC documented in P#1's medical record on 3/12/22 regarding the incident with P#1.

Review of the entire medical record for P#1 that was provided to the surveyors failed to reveal a Clinical Note by MSW CC that was dated on 3/12/22 concerning P#1.

During the exit conference with the Chief Executive Officer (CEO) TT on 4/6/22 at 6:00 p.m., the CEO was allowed to view the clinical note by MSW CC. The CEO verified that the note had the facility patient sticker and was written on paper from the facility.


Review of the "Medical Record Completion" policy #RC 15, reviewed 1/2022, revealed that medical records would receive regular analysis of documentation in the medical record. The goals included but were not limited to managing the content of the medical record and communicating patient care information. All medical records would be analyzed for completeness within thirty days of the last visit. Staff would check off deficiencies on an analysis sheet to be attached to the front of the medical record. The medical record would be forwarded to the responsible practitioner to complete. A monthly findings summary for each practitioner would be forwarded to the appropriate staff for appropriate action if necessary. Staff would ensure that all loose items, i.e., reports or slips, were filed into the medical record. The medical record folder would be reviewed to ensure good physical condition, accurate medical record number, correct year label, and patient identification were placed on outside of the folder.

Review of the "Incident Reports" policy, PI Risk 3, reviewed 1/2022, revealed that a report that an event happened to a patient with a description of the event with documentation identifying that the physician was informed, and any subsequent care needed, would be documented. The incident report would not become part of the patient's medical record.