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Tag No.: A0115
Based on observations, staff interviews, review of one of one medical record (P1), and review of facility documents, it was determined that the facility failed to ensure that patients receive care in a safe setting.
Findings include:
A safe patient care setting after a witnessed event of non-hospital personnel dragging a patient across the floor by the ankles, 1) by failing to mitigate the situation and/or remove the non-hospital personnel from the room, 2) failure of the 1:1 monitor assigned to the patient to notify hospital staff as the event occurred in accordance to the job description, and 3) failure to remediate or reeducate 1:1 monitor before reassigning to care for another patient. (Cross refer to Tag A0144)
That patients are free from abuse by failing to report in a timely manner, the witnessed event of a developmentally impaired patient being dragged by the ankles across the floor by two group home staff. (Cross refer to Tag A0145)
Tag No.: A0144
Based on a review of Patient #1's medical record, staff interviews, and review of facility documents, it was determined the facility failed to ensure that a safe patient care setting was provided following a witnessed incident of two group home personnel dragging a patient across the floor by: 1) failure to mitigate the situation and removal of the group home personnel from the patient's room; 2) failure of the 1:1 monitor (observer) assigned to the patient to notify hospital staff as the event occurred in accordance with their job description and facility policy; and 3) failure to remediate and reeducate 1:1 monitor (observer) prior to being reassigned to a 1:1 observation of another patient.
Findings include:
1.) Reference: Facility document titled, "Patient Rights and Responsibilities [hospital name] Somerset" dated 8/18/2021 states, "... A patient has the following rights ...Freedom from Abuse and Restraints: To freedom from physical and mental abuse ...Personal Needs: To be treated with courtesy, consideration and respect for your dignity and individuality ..."
A review of Patient #1's (P1) medical record on 2/2/23 at 1:04 PM, revealed the following:
On 1/28/23 at 2:27 PM, P1 arrived in the Emergency Department (ED) via wheelchair from the Group Home for "evaluation of crisis mode and self-inflicted injury to face and body."
At 4:30 PM, under section titled, "ED RN (registered nurse) Updates" S34, an ED nurse, documented "... pt [sic] [patient] numerous bruises throughout entire body and bilateral black eye [sic]. pt has swollen lips with dried up blood in mouth. Pt has bilateral abrasions to knees with bruising down kneecaps..." At 2:40 PM, first provider evaluation by S15, a physician's assistant, was documented.
At 2:59 PM, S15 ordered for "1:1 patient" [observation].
At 9:07 PM, in the section titled, "Collateral Information" S36, an ED nurse documented, "... Per collateral: Pt is unstable and unsteady. Pt's self-harming behavior is increasing. Pt sustained 5 major head injuries in which one required 8 staples in [his/her] head. Pt throws [his/her] head back on the floor and bangs it on things...Pt has been to the ER [emergency room] 3 X [three times] in the last 4 days and has not gotten the help needed. Last night pt injured [his/her] eye, reinjured lips, damage to face and was taken to [hospital name] where [he/she] was given a CT [computed tomography] and discharged this morning as there was not [sic] 'medical damage'... As a last resort to get pt help to stabilize, staff brought pt to [facility], an hour away to get assistance."
On 1/29/23 at 10:39 AM, in the "Clinical Notes" documentated by S8, a social worker, stated, "...received call from [S15] on 1/28/23 at 9 PM ...Group Home reported self inflicted facial injuries however medical professional suspected possible abuse in the form of what could be restraint marks on patients wrists and ankles. Patient uses Wheelchair. This case was called to the DDD [Division of Developmental Disabilities] Hotlie [sic] at 9:10 PM on 1/28 ...received call back from [name] on call DDD representative .... gave [him/her] background on patient and [he/she] will be investigating case from here..."
On 1/29/23 at 7:10 PM, documentation in "ED RN Updates" by S14 stated, "Received patient on the floor being manhandled and dragged by ankles across floor by group home workers. Locks of patients hair found on the floor. [S17, 1:1 monitor] in the room also. Group worker insisting on patient having shower. Explained that we can wash patient up in the bed but would like to wait till patient is settled down ...This RN and [S34] approached patient while patient was curled up in the corner. Therapeutic communication was used. Patient Stood up and put underwear on self..."
At 8:10 PM, documentation by S14 stated, "Spoke to [S16] [the nursing supervisor]. [He/She] will be coming down to assess...will send down CCT to replace patient monitor and to inform group home workers that nursing staff will be handling patient care."
At 8:14 PM, "Clinical Notes" documentation by S9 stated, "...RN updated DDD Special Response Unit was called due to suspected abuse from group home staff...RN shared Security has been involved as a group home staff is causing patient to be upset..."interfering with care." There are currently 2 female staff currently present. ER is providing 1:1 sitter...If ER staff is providing 1:1 and the group staff is not helping, it is up to the supervisor if the group staff are asked to leave or just have 1 Staff person present..."
At 10:23 PM, documentation by S14 indicated that the group home personnel was still present in the room.
Review of the progress notes by S32, a psychiatrist, dated 1/30/23 at 1:15 PM stated, "... ER staff brought concerns about patient possibly being abused by group home staff due to bruising and this was reported over the weekend to DDD. There were concerns about 2 group home staff staying in patient's room and...refusing to leave patients room; reportedly ER staff observed group home staff dragging patient by [his/her] feet...PLAN...continue 1:1 with suicide precautions, due to self harm; as well as due to concerns of abuse from group home staff. Will defer to nursing staff about the need for group home staff presence in the patient's room, in the context of concerns of possible abuse to the patient ..."
On 2/2/23 at 10:55 AM, in the Emergency Department, during an interview with S11, the ED director, the following was revealed:
S11 stated that on 1/29/23 at 9:00 PM, S14 notified him/her concerning the incident that occurred involving P1 and the group home workers where the patient was dragged across the floor by the GHWs [Group Home workers]. During the interview, S11 further stated that S14 had notified the ED charge nurse and the nursing supervisor. S11 then stated that upon arrival to work on 1/30/23 at 6:15 AM, he/she checked the staffing report and reviewed P1's medical record. S11 stated he/she had concerns regarding the bruising on the inner thighs and escalated the concerns to the psychiatrist. S11 continued that he/she does not remember telling anyone else but had called the Crisis Unit and was informed that DDD (Division of Developmental Disabilities) had been notified.
2.) Reference: Facility document titled, "Staff Job Description: Job title - Patient Monitor" (undated) states, "... Job Specific Requirements: Essential Functions: ...Observes and reports patient's conditions, behavior, and complaints to the nurse ... Maintains a safe and orderly work/patient environment ... Patient Monitoring: ... Close observations: maintains safety of close observation patients per policy ... Demonstrates competence in the following: Recognizing and reporting patient's behavior to members of the health care team ... Identifying appropriate situations to seek assistance from members of the nursing staff and/or security ..."
Reference: Facility document titled, "Patient Safety Watch in Non-Behavioral Health Setting" dated 10-1-2021 states, "... 3. Procedure...Every 15 to 30 minute Check:... RN or designated Staff Member: The Patient Watch Observation Form will be completed noting the behavior of the patient ... and report any changes in patient status or behavior to the RN immediately..."
On 1/29/23, S17 was assigned to be the 1:1 monitor [observer] for P1. At 7:10 PM, when the incident concerning P1 and the group home workers occurred, S17 who was present in the room failed to alert the nursing staff of the ongoing incident.
On 2/2/23 at 2:40 PM, during a phone interview with S14, an ED nurse, stated that he/she responded to the call light and heard someone banging on the door. Upon entry, S14 stated that P1 was on his/her stomach on the floor with each GH [group home] worker pulling the patient by the ankles. During the interview, S14 further stated that it was "chaos in the room" and that he/she asked the 1:1 monitor (S17) "why are you not doing anything?" S14 then stated that the patient monitor was switched for a CCT [clinical care technician].
At 3:10 PM, during a phone interview, S17 stated that he/she was the patient monitor in the room on 1/29/23, and stated, " ...there was so much going on ...I do not recall what happened ...after everything I told [S16] I was not comfortable in the room ..." S17 then stated that he/she was reassigned to another patient for 1:1 observation.
On 2/3/23 at 12:43 PM, during a phone interview, S17 stated that if a patient is agitated he/she should "redirect them" but if unable then he/she should alert the nurse, speak to the patient and tell them why they should not sit in front of the door, give reassurance then touch them make them feel comfortable. S17 stated he/she was "not sure" who pressed the call bell on 1/29/23 and stated, "I think they [GH staff] did...the call bell was pressed after the nurse came in to call for extra help..."
3) On 2/3/23 at 1:16 PM, during an interview with S1, in the presence of S3, S1 stated that after the incident with P1 on 1/29/23, the 1:1 monitor (S17) was replaced in the room with a CCT and then reassigned to another 1:1 patient to finish out the shift. S1 confirmed that there was no remediation or education provided at the time. S1 further stated that [S17] has not been forthcoming when questioned about the incident by management or when questioned by the police. According to S1, S17 has not been on the schedule since 1/29/23 and before [he/she] can return reeducation, remediation, and re-orientation will be provided.
On 2/3/23 at 5:23 PM, S1, S3, S19, and S20 were notified that the above findings resulted in an Immediate Jeopardy (IJ), and a copy of the completed IJ template was provided.
On 2/6/23 at 12:27 PM, an acceptable IJ removal plan was received.
On 2/6/23, verification of the Removal Plan was done, consisting of a tour of the emergency department (ED) and the cardiology unit 2-West, staff interviews with Registered Nurses (RN), CCT, Social Workers, Security staff, and department managers, review of one of one medical record (P1), and review of facility documents. It was determined that the facility had admitted the patient to a medical unit under the care of the Hospitalist team. The patient monitor (PM) who failed to notify staff of the witnessed event was relieved of duty until the completion of a job specific re-orientation, competency validation, and direct observation of job responsibilities. All PMs [Patient Monitors] were reeducated on the requirements for performance as stated in their job description. During tours of the ED and the cardiology unit 2-West, interviews were conducted with Staff (S) 26, S27, S28, S29, and S30 all stating they had received education prior to their shifts regarding policy changes and notification of suspected or witnessed abuse. Revisions were made to the following policies: Suspected Abuse, Neglect, or Exploitation of Adults, Reportable Cases to Authorities RWJUH Somerset, and Workplace Violence Policy: Response Process for Leadership. Development and implementation of the Adult Abuse Process Flow Algorithm in the ED for patients who present with suspected abuse. Education for all clinical staff including nurses, CCTs, PMs and mental health associates. Education for all security staff, case management/social work, and management including executives, directors, managers, and supervisors. Review of facility documents included education power points and sign in sheets, auditing tools, policy revisions, and documentation of notification to staff who have not completed the required education, that the education must be completed before return to work.
Tag No.: A0145
Based on a review of one of one medical record (P1), staff interviews, and review of facility documents, it was determined that the facility failed to ensure that patients are free from all forms of abuse and that suspected incidents of abuse are reported, analyzed, to include appropriate corrective actions in accordance with the facility policy.
Findings include:
Reference: Facility document titled, "Suspected Abuse, Neglect, and Exploitation of Vulnerable Adults and the Institutionalized Elderly" dated 4/8/2022 states, "...8. If the social worker is concerned that a crime has been committed that resulted in the abuse or neglect of a vulnerable adult, the social worker will discuss making a police report with the patient/patient representative, appropriate investigative agency, the Quality & Risk Depart., and the Director of Care Management &/or the Administrator on call. If the decision is made to contact the police, any such contact will go through Public Safety..."
On 2/2/23 at 10:55 AM, during tour of the ED (Emergency Department), an interview with S11 (ED Director) was conducted. S11 stated that on 1/29/23 at 9:00 PM, he/she was notified that a patient arrived in the ED on 1/28/23 from a group home with bruises at various stages of healing. According to S11, on 1/29/23 at 7:10 PM, the oncoming nurse had gone to the room and found [P1] on the floor on [his/her] abdomen, being dragged by the ankles by the GH workers and saw locks of the patients' hair on the floor. S11 continued to state that S14 (ED nurse) had notified the ED charge nurse and the nursing supervisor of the incident. S11 stated he/she had concerns regarding the bruising on the inner thighs and that concerns were escalated to the psychiatrist. S11 further stated during the interview that he/she does not remember telling anyone else but had called the Crisis Unit and was informed that DDD (Division of Developmental Disabilities) had been notified. When questioned, if the police and NJDOH [New Jersey Department of Health] were notified, S11 stated that he/she did not know "others" needed to be notified and S11 stated, "we usually don't call the police directly. We will call security and they will notify the police."
During interview with Social Workers S6, S8, S7 and S9 in the conference room at 12:03 PM, S7 stated that the policy indicates that security calls the police if needed and that nursing or the physicians will notify security.
On 2/2/23 at 1:04 PM, a review of Patient #1's medical record revealed the following:
On 1/28/23, the first encounter, P1 presented in the emergency department with bruises at various stages of healing, abrasions, bilateral black eye, facial trauma, and restraint marks on the patient's wrists and ankles. S15, a physician's assistant, reported suspected abuse to S8, a social worker, at 9:00 PM. Documentation under clinical notes by S8 on 1/29/23 at 10:39 AM stated that DDD was notified on 1/28/23 at 9:10 PM.
On 1/29/23 at 7:10 PM, the second encounter, S14 ( ED nurse) documented an incident where S14 witnessed two group home workers dragging P1 across the floor by the ankles in the patient's room. According to S14's nursing notes under the "ED RN update" section, S14 reported the witnessed incident to S16, a nursing supervisor and to S9 a social worker, on 1/29/23 at 7:35 PM. Further review of the chart revealed that there was no evidence that the Police Department was notified regarding any suspected abuse or concerning the witnessed incident.
On 2/2/23, during telephone interviews with S16 and S14 revealed the following:
At 2:10 PM, during a telephone interview, S16 stated that he/she received a call from the ED on 1/28/23 regarding [P1] and gave approval to reach out to SW (social worker) for suspected abuse. On 1/29/23, S16 stated he/she received a call from S14 asking for advice or opinion on what to do with "group home staff being a little bit aggressive" and mentioned about P1 being "dragged." S16 stated he/she advised S14 to call the SW on call for advice on how to proceed. S16 stated he/she "got sidetracked" and made rounds at midnight and found P1 sleeping. S16 stated there was "no further follow-up." S16 continued that security is called if there is a suspected abuse or assault and that the police and upper management are notified. When questioned why the police and upper management was not informed of the incident, S16 stated that he/she did not feel it was an assault and that P1 was grabbed to keep the patient from harming his/herself.
At 2:40 PM, during a phone interview, S14 stated that on 1/29/23 after the witnessed event he/she notified the nursing supervisor that he/she was not comfortable with the way the GH (group home) staff handled P1. S14 stated he/she was advised by S16 to notify SW. S14 stated, S9 the social worker was notified and that S9 stated he/she would report the incident. S14 further stated that security was not called because "we had it handled." S14 went on to state that the staff do receive annual education on abuse, when to report, and safe handling of patients, but does not recall having education for the "chain of command on who to notify." S14 continued that on 2/1/23, he/she spoke with the Local Police Department (PD) after the NJ Department of Health reported the incident to the local police department.
The facility failed to report the suspected abuse on 1/28/23 and the witnessed incident on 1/29/23, to the local and state authorities.
The above findings were confirmed by S1, S2, S3, S19, and S20 on 2/3/23 at 5:23 PM.