HospitalInspections.org

Based on document review and staff interviews, the acute care hospital administrative staff failed to ensure the hosptial staff conducted a thorough investigation into 1 of 1 reviewed allegation of abuse and separated a staff member accused of abuse from all patients during the hospital staff's investigation. Please refer to A-0145.

The cumulative effect of these failures resulted in exposure of hospital patients to a staff member accused of abuse prior to the hospital staff conducting and completing a thorough investigation into the allegation of abuse and determining if the staff member committed dependent adult abuse. The hospital staff identified that Physical Therapist A provided care to 17 patients between 4/20/21 and 4/21/21.

Based on document review and staff interview, the acute care hospital's administrative staff failed to ensure the hospital staff fully investigated and documented their investigation for 1 of 1 allegation of possible dependent adult abuse on the Telemetry Cardiac Unit 9S (Patient #1). Failure to fully investigate and document the investigation potentially could result in the hospital staff failing to identify if a staff member committed abuse against a patient, and potentially allowing that staff member to continue working with other patients, potentially resulting in the staff member potentially abusing another patient. The hospital staff identified that Physical Therapist A provided care to 17 patients between 4/20/21 and 4/21/21.

Findings include:

1. Review of the policy "Suspected Dependent Adult Abuse and/or Neglect," effective 6/2019, revealed in part, "... MercyOne Medical Center will provide immediate protection to those dependent adults whose physical health and emotional welfare appear to be in jeopardy. Measures will be taken to keep the dependent adult separate from the alleged perpetrator until the investigation is complete." "... upon suspecting an occurance of dependent adult abuse or neglect ... Complete the 'Suspected Dependent Adult Abuse Report' ... This report needs to be completed and signed by the mandatory reporter involved in the assessment/treatment of the dependent adult."

The policy lacked instructions for the hospital staff on how to address allegations of dependent adult abuse by a hospital staff member or provide instructions for the hospital staff members to separate the alleged perpetrator from all other patients while the hospital staff conduct their investigation.


2. Review of hospital documentation from 4/22/21 at 6:24 PM, Patient #1's Family Member informed the hospital staff they felt the hospital staff abused Patient #1 on 4/20/21 (2 days prior). Patient #1's Family Member informed the hospital staff that a hospital staff member woke Patient #1 up by screaming at Patient #1 in Patient #1's face, grabbed Patient #1's legs to throw Patient #1 out of bed, and threw a package of cleaning wipes on Patient #1's tray and told Patient #1 to clean themself up.


3. During an interview on 4/28/21 at 12:45 PM, Nurse Supervisor D revealed that on the morning of 4/20/21, Registered Nurse (RN)C provided care to Patient #1. Patient #1's Family Member informed RN C that a staff member assaulted Patient #1. RN C immediately informed Nurse Supervisor D about the allegations. Nurse Supervisor D then interviewed Patient #1 and Patient #1's Family Member about the allegations.

The next day (4/21/21, 1 day after the allegations), Nurse Supervisor D reviewed Patient #1's medical record and determined that Physical Therapist A provided care to Patient #1 around the time Patient #1's Family Member accused the hospital staff of abusing Patient #1. Nurse Supervisor D interviewed Physical Therapist A, who denied abusing Patient #1. Nurse Supervisor D verified Physical Therapist A would not provide further care to Patient #1.

Nurse Supervisor D did not interview any other staff members regarding Patient #1's allegation of abuse, including other witnesses to the events. Nurse Supervisor D failed to document their investigation, the interviews conducted as part of their investigation, or the results of their investigation. Nurse Supervisor D failed to ensure Physical Therapist A, who Patient #1 accused of abuse, did not work with any other patients until the hospital staff concluded the investigation.


4. During an interview on 4/27/21 at 10:30 AM and a follow-up interview on 4/28/21 at 2:52 PM, Physical Therapist A revealed they worked with Patient #1 on the morning of 4/20/21 (the date of the allegation of abuse). Physical Therapist A attempted to assist Patient #1 out of bed, but Patient #1 refused to get out of bed. Patient #1 then asked Physical Therapist A to clean up Patient #1, as Patient #1 was incontinent of stool. Patient #1 refused to assist Physical Therapist A in helping to clean up Patient #1. Patient #1 became upset towards Physical Therapist A and Physical Therapist A left Patient #1's room.

Physician's Assistant E was standing outside Patient #1's room on the morning of 4/20/21, during the interactions between Physical Therapist A and Patient #1, and overheard the interactions. Physician's Assistant E complimented Physical Therapist A for the way they handled Patient #1.


5. During an interview on 4/28/21 at 1:27 PM, Nurse Director B revealed Nurse Supervisor D contacted them regarding Patient #1's allegation of abuse on 4/20/21 (the day of the allegation). Nurse Supervisor D later informed Nurse Director B about Nurse Supervisor D's interview with Patient #1's Family Member and Physical Therapist A. Nurse Director B instructed Nurse Supervisor D to follow up with Patient #1's Family Member to determine if the hospital staff could do anything to make Patient #1 feel safe in the hospital. Nurse Supervisor D failed to follow up with Patient #1's or Patient #1's Family Member.

Nurse Director B failed to ensure that Nurse Supervisor D conducted a thorough investigation, including interviewing all witnesses. Nurse Director B also failed to ensure that Nurse Supervisor D ensured that Physical Therapist A did not work with any other patients until the hospital staff concluded their investigation.


6. During an interview on 4/29/21 at 10:50 AM, the Chief Nursing Officer verified that Nursing Supervisor D failed to conduct a thorough investigation into Patient #1's allegation of abuse by failing to interview Physician's Assistant E, who witnessed the interactions between Physical Therapist A and Patient #1. The Chief Nursing Officer verified that Nursing Supervisor D failed to document their investigation into Patient #1's allegation of abuse, the interviews Nursing Supervisor D conducted as part of their investigation, or the outcome of Nursing Supervisor D's investigation into Patient #1's allegation of abuse. The Chief Nursing Officer verified that Nursing Supervisor D failed to ensure Physical Therapist A did not work with any patients while the hospital staff conducted their investigation into Patient #1's allegation of abuse.