HospitalInspections.org

Based on interview and document review, the facility failed to develop and implement a policy that protected patients from an alleged abuser while an investigation was in progress, resulting in the potential for unsatisfactory outcomes for any of the 24 patients on the 6 Center unit. Findings include:

See specific tag A-0145.

Based on interview and document review, the facility failed to develop and implement a policy that protected patients from an alleged abuser while an investigation was in progress, resulting in the potential for unsatisfactory outcomes for any of the 24 patients on the 6 Center unit. Findings include:

On 3/3/21 at approximately 0945, interview with Nurse Manager F, revealed that she had been investigating an allegation of abuse of patient #1. The Manager was queried about the disposition of the alleged (sexual) abuser and she stated that he was reassigned to another section of patients while the investigation was in progress, their policy was not automatic suspension. The Manager stated that patient #1 had been assigned only female staff after the accusation. The Manager stated that the patient complained of "teenagers coming in her room" and was mildly confused. The Manager also stated that the local police had been called and had interviewed the patient and were performing their own investigation.

On 3/3/21 at approximately 1000, patient #1 was interviewed. Patient #1 stated a male nurse named XXXX woke her up from sleeping and he stated, "You didn't pee today." The patient stated: "He hit/tapped my leg twice on my knee" (she demonstrated tapping on her left knee) -- "I was upset and called my husband." "He is not my nurse." She then stated, "No great big deal."

On 3/3/21 at approximately 1015, review of patient #1's medical record revealed that she was a 79-year-old female admitted to the facility with metabolic encephalopathy (problem with the brain), urinary tract infection, and COVID-19 infection. Further record review with the Nurse Manager F revealed that patient was treated and had been transferred to the current unit 6 Center on 2/27/21 around midnight. The patient developed urinary retention and required catheterization.

On 3/3/21 at 1500, interview with the Attending Physician S revealed that he was made aware of patient #1's allegation. When queried of patient #1's mental status he stated, "(She) was in and out." The Attending Physician further stated that the patient's encephalopathy was treated but the patient still had periods of confusion.

On 3/4/21 at approximately 1300, re-interview with Nurse Manager F, revealed that the facility investigation of the alleged abuse was not complete. She stated that it was "a collaborative effort with Risk Management and Human Resources...interviews were still in progress."

On 3/4/21 at approximately 1330, review of the facility policy titled ""Abuse and Neglect Report, ID 8896567, revised date 11/2020" documented, "4. The nurse manager may elect to: a) change the assignment of the caregiver; b) Transfer the patient to another room or unit; c) Suspend the associate(s) allegedly involved pending further investigation." This policy as written and implemented did not protect the patient or other patients from abuse when an alleged perpetrator was allowed to continue to work in the hospital, having access to other patients, while the full investigation was not complete.