HospitalInspections.org

Based on record review and confirmed through staff interview the facility failed to report allegations, by 2 applicable patients, of abuse to the appropriate State Agency (SA) in accordance with Vermont State Statute Title 33 Chapter 69. (Patients #1 and #3). Findings include:

Per V.S.A. Title 33, Chapter 69, ? 6903. Reporting suspected abuse, neglect, and exploitation of vulnerable adults
(a) Any of the following, other than a crisis worker acting pursuant to 12 V.S.A. ? 1614, who knows of or has received information of abuse, neglect, or exploitation of a vulnerable adult or who has reason to suspect that any vulnerable adult has been abused, neglected, or exploited shall report or cause a report to be made in accordance with the provisions of section 6904 of this title within 48 hours:
Per review, the hospital policy, "Title: Assessment of Abuse and Neglect Reporting for Children and Vulnerable Adults" (Policy A-220, effective date 5/19/14) states on page 4 that "Abuse should be reported by mandated reporters when any mandated reporter has any reason to suspect that a vulnerable adult has been abused, neglected, or exploited. It is not up to the healthcare professional making the report to make the assessment of whether or not abuse has occurred. When unsure or in doubt, the report should be made....."

1. Per record review, on 6/23/14, Patient #1, who was admitted on an involuntary basis on 4/15/14, and whose diagnoses included schizoaffective disorder, bipolar type, currently manic, had a Discharge Planning Note, dated 5/22/14, that stated "....Pt makes numerous claims of staff physically abusing [him/her]; shows bruises s/he reports were caused by staff. SW (Social Worker) informed pt [s/he] can file complaint if this is the case. Pt requested paperwork & assistance. SW will follow up..." Subsequent Discharge Planning Notes, dated 5/26/14 and 5/27/14, respectively, revealed the following: "....Pt reports [s/he] is writing up complaints against staff [s/he] claims physically harmed [him/her]. This activity appears to be agitating pt to some degree. Pt reports [s/he] is struggling to write things down but that an RN (Registered Nurse) agreed to help [him/her] this eve." and, "...Pt provided papers [s/he] has been working on, complaints re staff members pt believes physically harmed [him/her]. Papers were barely decipherable...." Despite the documentation, there was no evidence the allegations, by the patient, of abuse by staff had been reported to the SA.
During interview, at 11:33 AM on 6/25/14, the staff member responsible for writing all three notes, confirmed that s/he had not reported the patient's allegations to the SA. The Nurse Manager for the unit on which Patient #1 resided stated, during the same interview, that generally, if there are complaints from patients, the patient's care team looks at how credible the complaint is, then makes the decision about whether or not to report.
The Quality Improvement Consultant, also confirmed, during interview on the morning of 6/25/14, that there was no evidence a report had been made to the SA.
2. Per 6/23/14 medical record review, Patient #3 was voluntarily admitted to the inpatient psychiatric unit on 4/9/14 with diagnoses that included schizoaffective disorder with worsening psychosis. A unit SW documented in his/her Discharge Planning Note (dated 4/17/14 at 1323) that Patient #3 "did not want any further contact with [the care facility where s/he had resided] and did not want to go back there on discharge ..." S/he reported wanting to stay "here" [the hospital]. The note further documented that the "Pt was vague re reasons for not wanting to return ...., became anxious, sighing heavily and putting [his/her] head down ..." The next Discharge Planning Note, dated 4/17/14 at 1641 documented that, "Pt spoke at some length re [his/her] conviction that [s/he] had been 'verbally abused' by two staff at the [care facility where s/he had resided]. Pt stated [s/he] did not want to return to that residence on dc." The staff member who documented the above allegations was not available for interview during the survey.

The facility was not able to provide evidence that the allegations made by Patient #3 were reported to the SA. On 6/24/14, the SA confirmed that no report had been received.

Based on staff interview and record review, nursing staff failed to provide consistent reassessment and management of pain for 1 of 6 applicable patients, in accordance with accepted standards of nursing practice and hospital policy. (Patient #4). Findings include:

Per record review during the survey (the period from 6/23/14 - 6/25/14), Patient #4 experienced post-operative pain, after surgical repair of a fractured left hip, self reported as #10 on a scale of 1-10 as documented by Registered Nurses (RN) providing care during 4 sequential pain assessments, starting on 6/22/14 at 2000 hours through 1130 hours on 6/23/14. Based on record review and confirmed by staff interview, there was a lack of evidence of consistent management, through nursing assessments and administration of the prescribed analgesics, within ordered time parameters, to effectively treat this patient's pain. The patient's acceptable stated level of pain was rated as #2 and #4, at separated times.
The nursing progress note dated 6/22/14 at 2305 stated that Patient #4 arrived on the medical surgical unit (from the Special Care Unit) at 2050 hours. Review of the electronic Medication Administration Summary, with the RN Educator at 10:50 AM on 6/24/14, showed that the patient received OXY-IR, 2.5 mg., (Oxycodone Immediate release) at 2152, X 1 (times 1) for pain rated at 10/10. There was no documentation of a follow up reassessment at 2 hours post administration of pain medication. At 0326 hours on 6/23/14, the RN wrote "PT rating pain 10/10, given .....PRN Tramadol w/good effect". The nurse documented in the same progress note (6/23/14 at 0326) that the patient also received PRN OXY-IR (2.5 mg.), however, that was given at 9:37 PM the previous night. The hospital's policy "Pain Assessment and Management Standard of Practice", 5. stated "Pain reassessment will occur within two hours after a pain relief intervention...". There was no evidence of reassessment post medication administration within the 2 hours, as required. The next medication administered was Tramadol 50 mg PO at 0919 HR. after the patient rated their pain as #10. At 1130 HR, the patient rated their pain as #10 again and was administered Oxycodone 2.5 mg IR and Tylenol, 650 mg PO. The lack of reassessment of the patient's pain levels per the hospital's policy was confirmed during interview with the Vice President (VP) of Quality on 6/25/14 at 8:15 AM.

Reference: Per Vermont title 26: Professions and Occupations, Chapter 28, Nursing, "Registered Nursing " means the practice of nursing which includes: (A) Assessing the health status of individuals and groups; (H) Maintaining safe and effective nursing care rendered directly or indirectly; (I) Evaluating response to interventions; (L) Collaborating with other health professionals in the management of health care.

Based on staff interview and record review, nurses failed to assure that the plan of care related to pain management was reviewed and revised to reflect the current needs for 1 of 10 patients in the total sample. (Patient #4). Findings include:

Per record review and confirmed during staff interview, Patient #4 experienced pain self-rated as #10 (severe) on multiple occasions during the hospital stay and staff failed to develop and revise a plan of care to reflect the patient's on-going issues with achieving relief from severe pain. The care plan for Pain, dated 6/15/14, stated: "Tolerable level of pain" as the goal. The interventions stated were: "Pain, provide routine comfort measures;
-position for comfort
-be alert for denial of pain
-encourage pt. to ask for pain med early
-administer med prior to activity"

Per review of the medication administration records, staff failed to develop a consistent, routine pattern of assessment and reassessment of the patient's pain. The care plan did not reflect that the patient was frequently rating their pain as #10 of 10. During the time period from 6/22/14 at 2:56 AM - 6/23/14 at 11:30 AM, the patient reported pain as #10 five times.
The hospital policy: Multidisciplinary Patient Assessment stated under Policy: "Reassessment : of care needs is evaluated.....and the plan of care is updated as appropriate". Under Procedure: A. Nursing, "The RN (registered Nurse) will initiate the care plan". Under Part II., A., The care plan is linked to and based on the assessments as previously described as well as physician input, orders and clinical changes."

During interview on 6/14/14 at 3:35 PM, the VP of Quality, after reviewing the above care plan for pain, stated, "It wouldn't pass my audit... not what I would want to see " regarding a patient with this level of pain.