HospitalInspections.org

Based on document review, record review and staff interview it was determined the facility failed to ensure staff followed the facility's policies for Patient Safety Event Reporting and Workplace Violence Prevention. This deficient practice was identified in one (1) of one (1) records reviewed (patient #1). This failure has the potential to adversely affect the rights of all patients, resulting in the patient not receiving care in a safe setting.

Findings include:

1. Review of the facility policy titled "Patient Safety Event Reporting", publication date 2/11/16, revealed it states, in part: "The emphasis on safety and the responsibility for improving safety resides at all levels of the organization...All employees are empowered and expected to participate in the detection and reporting of any observed adverse event, near miss, or unsafe condition by completing a safety event report via the Safety Report Manager (SRM)...It is the duty of all staff to report actual and near miss events via the SRM...the report should be completed in its entirety immediately after the event, and prior to the end of shift in which the event happened or was discovered."

2. Review of the facility policy titled "Workplace Violence Prevention", publication date 12/20/16, revealed it states, in part: "Charleston Area Medical Center has a zero tolerance policy for workplace violence...The safety and security employees, staff, patients and visitors are a vital importance to CAMC. Acts or threats of physical violence, including intimidation, harassment or coercion will not be tolerated at CAMC...Even without an actual threat, personnel should report any behavior they have witnessed which they regard as threatening or violent, when the behavior is related or might be carried out on a CAMC site, or is connected to CAMC employment...Employees shall report immediately any acts or threats of violence occurring on CAMC premises to the Director of Security, their supervisor, or to the Human Resources Department...Supervisors shall report immediately any acts or threats of violence to the Director of Security, their immediate supervisor, or the Human Resources Department...Supervisors/Managers are required to report any warning signs of violence that they observe (for example; verbal abuse, aggressive behavior, loitering, etc.)...The Director of Security will maintain incident reports and security reports pertaining to workplace violence."

3. Review of the medical record for patient #1 revealed a nursing narrative note dated 1/30/17 at 10:23 a.m. which stated, in part: "Patient getting angry and cussing at the health care workers...Patient was spitting on the curtains...Very agitated and throwing chairs in the bay and he hit his toe and started cussing again."

Review of a nursing narrative note dated 1/30/17 at 10:24 a.m. revealed it stated, in part: "Patient very irate, swearing and threw a chair in his room...Remains very irate, swearing and banging the chairs around...Security called and escorted patient and family from department."

Review of another nursing narrative note dated 1/30/17 at 10:24 a.m. revealed it stated, in part: "Security called to help us escort patient out of the department, he is very agitated and giving the health care workers the finger...Patient left the unit with security guards and with his middle finger in the air."

4. An interview was conducted on 2/20/17 at 1:02 p.m. with Registered Nurse (RN) #1. During the interview she stated: "The patient was swearing and throwing chairs." She reported security was called and two (2) people from security escorted the patient out. She also stated: "I guess we just didn't think of making up an incident report." She confirmed no safety report/incident report had been filed.

5. An interview was conducted on 2/21/17 at 8:11 a.m. with RN #2. During the interview she stated: "We have patients walk out all the time. We were all talking about if we should file a safety report, but we didn't do it because the patient walked out." She confirmed no safety report/incident report had been filed.

6. An interview was conducted on 2/21/17 at 11:33 a.m. with the Anesthesiologist/Medical Director of Operating Room. During the interview he stated: "The patient was out of bed, ranting and being disrespectful." He reported the patient could be heard in the holding area and "was not approachable to have a discussion about rescheduling the surgery".

7. An interview was conducted on 2/21/17 at 8:37 a.m. with RN #3. During the interview she stated: "The patient was in a cubicle, he was very loud and was using foul language." She denied any knowledge of a safety report/incident report being filed.

8. An interview was conducted on 2/20/17 at 12:22 p.m. with the Director of Surgical Services. During the interview she stated: "A safety report should have been done by the nurse taking care of the patient." She reported she had no knowledge of the incident until 2/20/17. She confirmed no safety report/incident report had been filed.

9. An interview was conducted on 2/20/17 at 12:45 p.m. with the Charge Nurse of Short Stay Surgery. During the interview she stated: "A safety report should have been filed by the nurse taking care of the patient." She also stated she didn't know about the incident until several days later. She confirmed no safety report/incident report had been filed.

10. An interview was conducted on 2/20/17 at 2:13 p.m. with Security Guard #1. During the interview he stated: "He was ranting and raving and I said let's go and he followed me out."

11. An interview was conducted on 2/20/17 at 2:13 p.m. with the Security Guard Supervisor. During the interview he stated: "We do not file a safety report if the patient is just asked to leave." He confirmed no safety report/incident report had been filed.

12. An interview was conducted on 2/22/17 at 9:14 a.m. with the Corporate Director of Patient Safety and Risk. During the interview she stated: "I would expect a safety report to be filed on an incident like this." She also stated: "If we don't know about these incidents we can't effectively monitor and establish a safe environment." She confirmed no safety report had been filed.