HospitalInspections.org

Based on hospital policy review, hospital document review, medical record review, and interview, the hospital failed to ensure patient rights were protected for 1 of 3 (Patient #12) sampled patients by failing to adequately monitor and protect Patient #12 from alleged abuse.

The findings included:

1. Review of the hospital policy titled "Abuse and Neglect of Patients", revised 5/2/2023, revealed, " ...PURPOSE ...To provide a standardized and systemic process for responding to an allegation or actual acute of abuse or neglect of a patient and to provide for a process to investigate and determine the facts pertinent to such an event. Additionally, to apprise all Hospital and Medical staff of their obligation to report such events and to always ensure the safety of patients ...All Hospital employees have an obligation to protect patients, prevent abuse or neglect from occurring and to report any and all information concerning occurrences where abuse or neglect may have occurred. An employee who witnesses abuse or mistreatment of a patient, and does not promptly report it to his/her supervisor is subject to disciplinary action ...Whenever there is an allegation of abuse or neglect, appropriate Hospital staff should immediately assess patient's personal safety, the potential of harm to the patient and/or other patients, including the removal of any alleged perpetrator from the patient care area ...EMPLOYEE RESPONSIBILITIES AND INITIAL NOTIFICATION PROCEDURE ...Employees who witness or have knowledge of patient abuse shall immediately report it to the Nurse Manager, Director or Charge Nurse, Administrator on call or Risk Manager. If for some reason, the employee believes they cannot or should not inform Nursing Supervisor, Administrator on call or Risk Manager, the employee may contact the Hospital Chief Executive Officer, Director of Nursing, Director of Quality Improvement, Medical Director, or the Compliance Hotline ..."

Review of the hospital policy titled "Patient Rights and Responsibilities", revised 8/14/2024, revealed, " ...patients have a right to care that safeguards their personal dignity and respects their cultural, psychological and spiritual values..."

2. Review of the "Hospital Investigation Report" (undated) revealed, " ...9/2/24 [2024] the patient [Patient #12] became severely agitated. He was kicking and cursing at staff and refusing care. He had removed his IV [intravenous]...IV therapy was called to replace the IV. The patient required the initiation of 4 point restraints and a vest restraint. The male primary RN [RN #1] was attempting to hold the patient down, the patient spit on the primary RN. Per the IVT [intravenous therapy] RN and charge RN who were present at the time of the event, the primary RN [RN #1] ised a closed fist to turn the patient's head to the side then placed his hand momentarily aroung the patient's throat. The charge RN requested that the primary RN [RN #1] leave the room and said she would assume the patient's care...The two female RNs in the room at the time of the event were very emotional during their separate interviews and relayed the event in the same details and felt the behavior of primary [RN #1], was very aggressive and they both stated their feelings that the patient was choked by the primary [RN #1] ...[Risk Manager] met with Patient #12 prior to his discharge. He [Patient #12] stated he recalled the [RN #1] being angry with him [Patient #12] and pushing his [RN A] fist against his [Patient #12] face ...." There was no documentation that the hospital staff assessed Patient #12's neck and face area post incident.

Review of the "Time Clock Record", dated 9/2/2024, revealed, RN #1 clocked in at 6:38 AM and clocked out at 7:13 PM.

Medical record review revealed Patient #12 was admitted to the hospital on 8/31/2024 with diagnoses which included Acute Encephalopathy and Sepsis.

Review of the medical record dated 9/2/2024, revealed Registered Nurse (RN) #1 performed toileting care for Patient #12 at 10:00 AM, 12:00 PM, 2:50 PM, 4:00 PM and 6:00 PM.

Review of the medical record dated 9/2/2024, revealed RN #1 obtained vital signs on Patient #12 at 10:00 AM, 11:00 AM, 12:00 PM, 1:30 PM, 2:50 PM, 4:00 PM, 4:12 PM, 5:00 PM and 6:00 PM.

Review of the Medication Administration Record (MAR) dated 9/2/2024, revealed RN #1 monitored Patient #12 dexmedetomidine (medication used for sedatio and anxiety reduction) drip from 10:00 AM to 6:46 PM.

Review the medical record dated 9/2/2024, revealed RN #1 reviewed Physician Orders for Patient #12 at 10:40 AM, 11:21 AM, 2:00 PM, 2:19 PM, 2:20 PM, 3:53 PM, and 4:01 PM.

Review of the "Progress Note" dated 9/2/2024 at 11:33 AM, revealed, " ... [Patient #12] severely agitated this morning and was spitting at staff and attempted to assault a nurse ...he [Patient #12] is coughing intermittently .... Skin assessment revealed, track marks on arms with large heeled linear scar on right upper forearm, dry skin on feet but no obvious open skin ulcers..."

Review of the medical record dated 9/2/2024, revealed, RN #1 completed a physical assessment at 2:50 PM on Patient #12.

Review of the MAR dated 9/2/2024, revealed RN #1 administered azithromycin (antibiotic) by mouth at 3:55 PM and piperacillin-tazobactam (antibiotic) via intravenous piggyback (IVPB) at 5:12 PM to Patient #12.

Although the hospital's investigation documented that the charge RN stated she would assume Patient #12's care, RN #1 continued to document that he provided care for Resident #12 after the incident and throughout the rest of his shift.

During a telephone interview on 3/3/2025 at 2:20 PM, RN #2 was asked to tell me about the incident. RN #2 stated, " ... I was the Charge Nurse that day...[RN #1] was mad about his assignment ...at some point [RN #1] and [Patient #12] was yelling at each other, and the whole team went in ...[Patient #12] had ripped out his IV because he was mad ...I restrained [Patient #12] and [RN #1] came back in and put pressure on his legs ...and [Patient #12] sat up and spit on him [RN #1]...[RN #1] pushed [Patient #12]'s head down with his fist and put a chokehold on [Patient #12]...I immediately made [RN #1] leave the room ... I don't recall any marks on [Patient #12]'s face and neck..." RN #2 confirmed she did not notify management of the incident and allowed RN #1 to continue provide care for Patient #12.

During a telephone interview on 3/4/2025 at 8:00 PM, the IVT RN was asked about the incident. The IVT RN stated, " ...I got a phone call that a patient needed a Dexmedetomidine drip right away and needed an IV ...When I got to the room two nurses were present...[RN #1] was at the foot of the bed and [RN #2] was at the far side of the bed ...[Patient #12] was already in restraints ...[Patient #12] sat up to a 30-degree angle and tried to spit on [RN #1] ...[RN #1] took his fist and hit [Patient #12] in the chin and then took his other arm and made a L shape and put it on [Patient #12]'s chest, then placed his forearm in [Patient #12]'s throat, and pushed [Patient #12] down on the bed...[RN #2] placed a mask on [Patient #12] and [RN #1] pushed [Patient #12] back down again ...[RN #2] asked [RN #1] to leave the room ...I reported the incident to ERS [Event Reporting System] on 9/2/2024 at 2:31 PM ..."

The hospital failed to ensure Patient #12's rights were protected by allowing RN #1 to continue care for Patient #12 after the incident and failed to ensure the safety of all patients. The hospital was unable to provide documentation that the abuse event was reported immediately. The hospital was unable to provide documentation the patient was immediately assessed for evidence of abuse and that follow-up care was provided. The hospital failed to provide training to RN #2 post incident that occurred on 9/2/2024.