HospitalInspections.org

Based on record review and interview, the facility failed to develop and implement a policy protecting patients from an alleged staff abuser resulting in the potential for poor patient outcomes for all patients served by the facility. Findings include:

See Specific Tag:

A-145 Failure to deveop and implement policy

Based on record review and interview, the facility failed to develop policies to ensure the prevention and protection of patients from an alleged hospital staff abuser resulting in the potential for unsatisfactory patient outcomes for all patients served by the facility. Findings include:

Review of the medical record on 5/14/2024 at 1420 revealed P-29 was a 51-year-old female with a past medical history of chronic pain issues, chronic kidney disease stage 3, depression, diabetes with neuropathy, hypertension, and peripheral artery disease. P-29 was admitted to the facility on 1/10/2024 for osteomyelitis, and, during her admission, had complications with acute respiratory failure and was placed on a ventilator.

Multiple nursing notes between 1/21/2024-1/23/2024 revealed P-29 had "frequent complaints" was "unsatisfied with care she has been receiving" and was "very demanding, calling various staff members inappropriate names." The nursing notes also revealed house director, management, security, and police involvement.

On 1/24/2024 at 0034, Registered Nurse (RN) Staff S documented that at 2110 P-29 was talking to her daughter on the phone making complaints. When the nurse attempted to explain what was happening, P-29 threw her medications across the room and "dumped her metamucil on bed as she was stating out loud for daughter to hear, that RN was doing those things... Daughter called desk telling unit clerk that she wanted a different RN caring for (P-29) stating the RN was rude to pt (patient) and slapped pt face."

Further review of the medical record revealed P-29 chose to leave AMA (against medical advice) on 1/23/2024 at 2345. Security took her by wheelchair to the discharge area. On 1/24/2024 at 0106, P-29 presented to the Emergency Department (ED) with a chief complaint of "Generalized Weakness (Recently admitted on 1/10 and Left AMA today. States she was hit by nurse and had IV 'tugged out'..."

ED Provider note dated 1/24/2024 at 0727 stated, "Of note, patient left last night AMA after possible altercation with nursing staff on our medical floor. Patient states however that she never left (hospital name) because she felt too weak. At this time, she has no new complaints however states that she does not feel like she is safe here and would like to go to another hospital." Physical exam stated, "No acute distress...SKIN: Normal for ethnicity." Nothing further was mentioned regarding the alleged assault. P-29 was offered re-admission to the facility; however, she refused.

On 5/16/2024 at 0840, Quality Director and Risk Manager Staff C reported after multiple phone calls and text messages there was no response for an interview from RN Staff S. Additionally, ED Physician Staff HH was out of the country and unreachable.

On 5/16/2024 at 0900, review of facility policy #4009 titled "(Facility Name) Standard Practice Allegations of Abuse By Staff" last revised 2/7/2022 states, " Definitions: A. 'Immediate' means at the time of witnessing conduct or receiving an allegation of conduct that is the subject of this policy. The requirements in this policy for 'immediate notification' apply even if the incident occurs after hours and/or on weekends and holidays... 'Assault' means any non-consensual touching. Assault includes physical and/or sexual assault... All employees, medical staff members and contractors are expected to immediately report any suspicions of abuse, neglect, or assault... Immediate Actions: Any employee, contractor or member of the medical staff who witnesses or receives an allegation of sexual or, physical abuse, neglect or assault of any patient or other individual must immediately ensure the safety of that individual, including but not limited to ensuring that a physical examination, if applicable given the nature of the allegations, is conducted... Once the immediate medical needs of the individual have been addressed, the Administrator on Call (AOC), or his or her designee, must be notified. The AOC, or his or her designee, must verify the safety of the individual, gather preliminary facts, and notify Associate General Counsel... Investigation: All internal reviews will be directed by Associate General Counsel. The Vice President of Human Resources or Chief Medical Officer, as appropriate, will be immediately notified and involved in the entire investigation... In responding to allegations of abuse, assault, or neglect made by a patient, the (initials for facility name) policy on Complaints and Grievances will also be adhered to and the Patient Relations Department must be notified... Individuals involved in the investigation will be responsible for maintaining complete documentation of the following: 1) All allegations of abuse, neglect, or assault; 2) The specifics of the allegations made; 3) The specific steps taken to investigate and review the allegations; 4) And the results of the review including the results of any review by law enforcement or other external agency. 5) Following the completion of the investigation, all documentation will be submitted to the Legal Department for retention."

The policy failed to include removal of the alleged perpetrator from all patient care pending investigation.

On 5/16/2024 at 0920, Director of Quality and Risk Management Staff C was queried as to if there was an incident report relating to the alleged abuse of P-29 to which she stated there was not. She further stated Public Safety had been with the patient near or at the time of the alleged assault and had conducted an investigation and the medical record had plenty of information regarding P-29's demeanor and behaviors.

On 5/15/2024 at 1025, a Security Report dated 1/23/2024 at 2318 revealed under the "Injury Status" area it stated, "No Injuries." There was no mention of an alleged assault or of a slap or a punch to P-29's face. When interviewed on 5/15/2024 at 1618, Public Safety Officer Staff CC stated he "did not recall the patient saying she was slapped. If she had, it would have been put in the report." He denied having investigated the alleged assault. He stated he had just gone to the room and talked with both the patient and the nurse.

On 5/16/2024 at 0846, House Director Staff FF stated he was not notified by staff of an alleged assault from nurse to patient. He stated he was called directly by the patient when she was waiting to be seen in the ED lobby. He recalled P-29 had been "abusive to staff" and that he was aware of the allegation of alleged assault of the patient. When queried as to if he had made an incident report or had documented this anywhere, Staff FF stated he had not and stated he was new to his position at the time and there was not really a place to document this.

On 5/16/2024 at 0929, Chief Nursing Officer (CNO) Staff B stated the house director should be notified of an alleged employee assault and would determine the need to contact the AOC. He stated the desired steps in this case would have been for the staff to contact the house director sooner, an incident report could have been made, and then public safety, the sheriff on site, and quality/risk could be involved. There was no process for the house director to call the risk manager directly.

On 5/16/2024 at 0943, Vice President of Patient Care Services Staff D, who was the administrator on call the night of 1/23/2024, stated not all calls would be recorded in a log, but rather, only ones of significance. When queried as to if an alleged staff to patient assault would have been recorded in the log, she stated, "Yes." Staff D was then asked to review the log to determine if an alleged staff to patient assault had been called to her on the night shift of 1/23/2024. Staff D confirmed on 5/16/2024 at 1015 there was no such entry on her log.