HospitalInspections.org

Based on record reviews and interviews, the facility failed to ensure that patients are free from all forms of abuse for 1 of 1 patient (patient #1). The facility failed to:
-Ensure that patients were protected from on-going physical abuse by removing the alleged perpetrator from patient contact.
-Ensure facility staff followed facility policy and procedure in reporting physical abuse of a patient.
-Ensure nursing staff documented reports of alleged abuse and conducted an immediate physical assessment of the patient after the abuse was made known.

Refer to A0145 for evidence of findings.

The cumulative effect of these deficient practices resulted in the facility's inability to meet the Condition of Participation for Patient Rights.

Based on record reviews and interviews, the facility failed to ensure that patients were free from all forms of abuse for 1 of 1 patients (patient #1). The facility failed to:
-Ensure that patients were protected from on-going physical abuse by removing the alleged perpetrator from patient contact.
-Ensure facility staff followed facility policy and procedure in reporting physical abuse of a patient.
-Ensure nursing staff documented reports of alleged abuse and conducted an immediate physical assessment of the patient after the abuse was made known.

Findings Included:

Record review of the medical record for Patient #1 revealed that she was a 89 year old female with diagnosis of severe end stage dementia, coronary artery disease, and chronic kidney disease. Patient#1 was being monitored by a non- recorded video camera manned by staff.

Record review of the facility Patient Event Records, dated 9/17/18 at 0632 revealed in part, the following information:
-On 9/13/18 at 1830 Video Monitor Technician #1 (VMT) witnessed husband grab patient by face.
-On 9/13/18 at 1910, VMT#2 witnessed husband grab patient by her face and hit her on her side.
- Supervisor notified: Yes, date 9/17/18 at 0633.
- Pre event condition: Confused.
-Event Severity: Unsafe situation could harm
-Further information related to cause: Patient hit by family member.
-Type of Treatment: Other, sitter placed in room.

Record review of the video monitors log dated 9/13/18 shift 7P-7A revealed the following:
- "family member punched patient on the lower end of her body. Reported it to house sup and called the unit and told Director of Telemetry unit.

Record review of the Hospital sitter log revealed the following:
- 9/13/18 at 12:00 am to 9/19/18 at 3:00 pm- (1:1 sitter reason) Patient's pulling out life preserving lines and restraints are contraindicated. Additional details: caregiver was witnessed trying to hit patient X2.

Record review of the facility Social Worker's progress notes revealed in part the following information:

-9/14/18 at 1609: "Case Manager (CM) was notified by director of Telemetry and video monitors that patient was seen being chocked and slapped by husband. CM rendered initial assessment, patient was not in the room, she was obtaining a colonoscopy .... Husband states he is the primary care giver for the patient and they live together in a single story home."

-9/17/18 at 1422: "Called APS case worker for an update. Informed patient was seen by weekend on call investigator based on 2 cases called in over the weekend. APS case worker communicated this was new case not a previously opened case ... ... Also stated that since it happened in a hospital was instructed by supervisor to report cases to DHHS (Department of Health and Human Services). "
- Plan: "DC disposition undetermined. Prior to admission there was not an open APS case. However, there were 2 cases called in this weekend. Weekend on call person came out. Above information will be communicated to patient's nurse, DC/Charge Nurse, and unit's Nurse CM."

Record review of the nursing notes dated 9/13/18 to 9/17/18 revealed that on 9/14/18 at 1816 nursing staff documented the following: "Had a conversation with investigator of APS. Stated patient has open adult protective services case, they will follow up with patient from now." Further review revealed that on 9/15/18 at 2021 Adult protective services (APS)visited the patient. There was no evidence that nursing staff documented the incident of physical abuse, assessed the patient immediately after the abuse occurred, documented the reason for the APS visit and/or notified patient #1's primary physician. Continued review revealed that nursing staff had documented that the patient's husband (alleged Perpetrator) stayed at the patient's bedside throughout her stay at the facility.

Record review of the physician's progress notes, dated 9/14/18 at 0815 through 9/17/18 revealed no evidence that Patient #1's primary physician was notified of the witnessed physical abuse of patient #1 that occurred on 9/13/18.

Further review of the facility documentation dated 9/13/18 to 9/19/18 revealed no evidence that facility staff reported the abuse to the Department of Health and Human Services.

Record review of the nursing discharge note dated 9/19/18 at 1439 revealed that the patient was discharged home to the care of her husband (alleged perpetrator).

Record review of the facility policy entitled: Abuse: Identifying, Documentation, and Reporting of Suspected Abuse, Neglect, and Exploitation, reviewed 3/2015 revealed in part the following information:

- Procedure:
1.) All suspected maltreatment must be reported as soon as possible before the end of the reporter's shift to Adult Protective Services.
2.) Allegations that occur on facility premises (adult and pediatric):
a) Call San Antonio Police to investigate, and collect evidence if needed.
b) Report allegation immediately to all of the following:
- Nurse Director/ Manager notifies administration and legal as appropriate
- Treating Physician
- Hospital Administrator in house or on-call
- Quality/ Risk Manager
c)Preserve evidence: Do not touch, attempt to clean, or discard anything associated with the allegation.
d) If there is an allegation of sexual assault or rape, notify the SANE nurse immediately.
e) Submit a preliminary report to Department of State Health Services. (Now HHSC)
f) Complete occurrence report by the end of the shift and submit to Quality/ Risk Manager and appropriate leadership.
6.) Elder Maltreatment: if the reported believes that immediate protection for the elderly person is advisable, the appropriate law enforcement agency having jurisdiction over the place where the incident occurred will be notified.... If the patient resides in a nursing home, and the maltreatment is suspected to originate in the nursing home, an additional report must be made to The Texas Department of Aging and Disability....

In an interview conducted on 11/14/18 at 10:45 am, the RN supervisor stated that the VMT reported to her that he saw the patient's husband slapping and chocking the patient. That day staff sent her husband home, but he came back the next day. When asked if she had documented the patient's disposition after the alleged abuse she stated she had not. When asked if she had reported the incident to the Department of Health and Human Services, she stated she was not aware she was required to do so.

In an interview conducted on 11/14/18 at 11:00 am the RN Case Manager revealed that she was on duty the day the physical abuse occurred. She stated that the VMT called and told her that patient #1's husband had hit her. She stated that she went to see what was going on with the patient. When she got to the room, the patient's husband was at the bedside. The husband appeared very frustrated so she sent him home and he came back the next day and sat at the bedside with the patient. When asked if she had assessed the patient after the physical abuse had occurred, she stated she had but did not document the assessment.

In an interview conducted on 11/14/18 at 11:15 am, the Director of Telemetry revealed that he was aware of an incident where the patient's husband shook her face and that the initial report was called in to APS. He further stated that he was not aware of any other reports of abuse that were called in for the patient.

In an interview conducted on 11/14/18 at 1:10 pm with the Chief Medical Officer (CMO)and the Director of Patient safety, the CMO, was asked by the surveyor why the patient's husband (alleged perpetrator) was not removed from contact with Patient #1 for the duration of her stay. He stated that the husband was not removed because he was the patient's responsible party. When asked by the surveyor if the alleged abuse was called in to the Texas Department of Health and Human Services (HHSC), both the CMO and the Director of Patient Safety stated that they were not aware that the incident needed to be reported to HHSC.

Based on record review and interview, The facility failed to ensure nursing staff documented reports of alleged abuse conducted an immediate physical assessment of the patient after the abuse was made known, and notified the patient's primary physician.

Findings Included:

Record review of the facility Patient Event Records, dated 9/17/18 at 0632 revealed in part, the following information:
-On 9/13/18 at 1830 Video Monitor Technician #1 (VMT) witnessed husband grab patient by face.
-On 9/13/18 at 1910, VMT#2 witnessed husband grab patient by her face and hit her on her side.
- Supervisor notified: Yes, date 9/17/18 at 0633.
- Pre event condition: Confused.
-Event Severity: Unsafe situation could harm
-Further information related to cause: Patient hit by family member.
-Type of Treatment: Other, sitter placed in room.

Record review of the facility Social Worker's progress notes revealed in part the following information:

-9/14/18 at 1609: "Case Manager (CM) was notified by director of Telemetry and video monitors that patient was seen being chocked and slapped by husband. CM rendered initial assessment, patient was not in the room, she was obtaining a colonoscopy .... Husband states he is the primary care giver for the patient and they live together in a single story home."

Record review of the nursing notes dated 9/13/18 to 9/17/18 revealed that on 9/14/18 at 1816 nursing staff documented the following: "Had a conversation with investigator of APS. Stated patient has open adult protective services case, they will follow up with patient from now." Further review revealed that on 9/15/18 at 2021 Adult protective services (APS)visited the patient. There was no evidence that nursing staff documented the incident of physical abuse, assessed the patient immediately after the abuse occurred, documented the reason for the APS visit and/or notified patient #1's primary physician. Continued review revealed that nursing staff had documented that the patient's husband (alleged Perpetrator) stayed at the patient's bedside throughout her stay at the facility.

Record review of the physician's progress notes, dated 9/14/18 at 0815 through 9/17/18 revealed no evidence that Patient #1's primary physician was notified of the witnessed physical abuse of patient #1 that occurred on 9/13/18.

Record review of the nursing discharge note dated 9/19/18 at 1439 revealed that the patient was discharged home to the care of her husband (alleged perpetrator).

In an interview conducted on 11/14/18 at 10:45 am, the RN supervisor stated that the VMT reported to her that he saw the patient's husband slapping and chocking the patient. That day staff sent her husband home, but he came back the next day. When asked if she had documented the patient's disposition after the alleged abuse she stated she had not.

In an interview conducted on 11/14/18 at 11:00 am the RN Case Manager revealed that she was on duty the day the physical abuse occurred. She stated that the VMT called and told her that patient #1's husband had hit her. She stated that she went to see what was going on with the patient. When she got to the room, the patient's husband was at the bedside. The husband appeared very frustrated so she sent him home and he came back the next day and sat at the bedside with the patient. When asked if she had assessed the patient after the physical abuse had occurred, she stated she had but did not document the assessment.

Based on record reviews and interviews, the facility failed to ensure that nursing staff were provided formal training in the use of Hoyer lifts before staff used the lifts in direct patient care.


Findings Included:

Record review of the medical record for patient #2 revealed that he was a 58-year-old male with diagnosis of Paraplegia, morbid obesity, Congestive Heart Failure, Diabetes, and atrial fibrillation. Further review revealed that he required a Hoyer lift for transfers due to his extreme weight.

Record review of the nursing notes dated 6/23/18 at 0323 revealed in part the following information:
-Pt wanting to be able to get out of the bed. Explained that once the lift (Hoyer) was evaluated by maintenance and patient worked with staff would do the utmost to get patient out of bed.

Record review of the nursing notes dated 6/27/18 at 0425 revealed in part the following information:
-Nurse Practitioner called on 6/26/18 at 22:00 and made aware of patient's bloody urine post repositioning in Hoyer lift.....

In an interview conducted on 11/13/18 at 1:20 pm, the Registered Nurse (RN) Manager stated that she was not trained in the use of the Hoyer lifts, which were installed on 11/2017. She stated that she had to "reach out" to maintenance personnel regarding how to use the Hoyer lift.

In an interview conducted on 11/13/18 at 1:45 pm, the RN charge nurse for the facility's 4th floor unit revealed that none of the nursing staff on the unit had any training on how to use the Hoyer lifts. She further stated that nursing staff had to call around to other units in order to find someone that could use the lifts and to obtain the sling components of the lift.

In an interview conducted on 11/13/18 at 2:20 pm, the 4th and 6th floor Nursing Supervisor revealed that there are a total of 5 patient rooms on the 4th floor which have Hoyer lifts installed in the ceiling. She further confirmed that nursing staff have had no formal training in how to use the Hoyer lifts.

In an interview conducted on 11/13/18 at 2:35 pm, the RN charge nurse for the Emergency Department (ED) revealed that staff in the ED have to call other units to find a Hoyer lift when needed. She further stated that not all staff are familiar with how to use the lifts. Staff would have to call the other units to find someone who could show them how to use the Hoyer lift.

In an interview conducted on 11/13/18 at 3:00 pm, the Director of Education confirmed that nursing staff have not been formally trained on the use of Hoyer lifts. She further stated that she normally would work with the manufacturer of the durable medical equipment in the training of hospital staff. However, she was unaware that the new Hoyer lifts had been installed, or that there was a need for training, so no training was done.