HospitalInspections.org

Based on interviews and record reviews, it was determined the facility failed to follow facility policies #12A, "Incident Investigations" and #35A, "Reporting Patient Abuse, Neglect, and Exploitation," related to protecting all patients in the facility from potential abuse, after an allegation of abuse had been lodged against a staff member, for one patient (#2), in the selected sample of four.

Findings include:

Review of the, "Facility Incident Management Protocol" revealed, "Reported, alleged, or suspected abuse, neglect, or exploitation" was defined as a Class 3 incident. Review of the Standard Operating Procedure #12A, "Incident Investigations" revealed all employees alleged to have committed a Class 3 incident would be moved immediately to a non-direct care position for the duration of the incident investigation process. Review of the Standard Operating Procedure #35A, "Reporting Patient Abuse, Neglect, and Exploitation" revealed that if an employee was accused of patient abuse, neglect, or exploitation, the employee would be removed from direct patient care, pending the outcome of the facility's internal investigation.

Review of the facility's internal investigation file revealed Patient #2 alleged on 01/30/11 at 4:40 PM, that a Patient Aide hit him/her in the face and pushed him/her while in the shower area. The Patient Aide was removed from the ward after the allegation was made.

An interview with the Patient Aide on 02/08/11 at 3:00 PM, revealed Patient #2 accused him of hitting him/her in the face and pushing him/her while in the shower area. The Patient Aide stated he was removed from the ward that Patient #2 was on, however, he was assigned to another ward and he provided patient care the rest of the 3:00 PM to 11:00 PM shift, on 01/30/11.

An interview was conducted on 02/11/11 at 11:05 AM, with the Quality Support Services personnel, (on call on 01/30/11). She revealed she had been made aware of the allegation of abuse on 01/30/11 and informed staff to move the Patient Aide to another area to work. She stated she understood the incident was observed by a witness and it was a false allegation, therefore, she allowed the Patient Aide to continue to work in the patient care areas. She later discovered she had misunderstood the details of the incident and the incident had not been observed by anyone.

An interview with the Risk Manager on 02/11/11 at 11:15 AM, revealed the Patient Aide should not have been permitted to work in the patient care area, until the allegation had been investigated. He stated allowing the Patient Aide to work was in violation of the facility's policies and procedures, related to protection of patients during an investigation of an allegation of abuse.