HospitalInspections.org

Based on medical record review, document review, policy review, and interview, the facility failed to report incidents of alleged abuse through their occurrence and incident reporting system. This finding was observed in two (2) of ten (10) patients in the sample (Patients #9 and #11).

Findings:

Review of Patient #11's MR on 10/2/24 identified on 9/18/24 at 10:07 AM, the social worker documented "Social worker met with patient at bedside this morning wherein the patient reported she was not well and that someone had locked her up and hit her during the night. -----".

On 9/18/24 at 4:09 PM, the nurse documented a noted that stated "Around 11 am I was called by the clerk that patient grandson wanted to talk to me. He was on the phone with patient's daughter----. Patient's daughter on the phone told me that the patient told them that someone slapped her last night".

Review of Patient #9's MR on 10/2/24 identified that on 7/22/24 at 3:20 AM, the nurse documented that the patient alleged that the nurse who was covering a break for the staff member who was observing the patient was masturbating in their room.

Review of the incidents/occurrences log on 10/2/24 identified that there were no incidents/occurrences reports filed for these incidents.

Review on 10/3/24 of the policy "Patient Abuse Occurring on Hospital Premises," last revised 06/2024, indicated the Director of Nursing/ADN/AOD or designee is responsible to "ensure any allegations of abuse, neglect, or harassment are reported through the facility's occurrence/incident reporting system and to risk management staff."

On 10/4/24 at 12:15 PM, when Staff I (Chief Quality Officer) was asked to provide any incidents/occurrences reports for these two (2) allegations of abuse, the facility was unable to provide any reports.

During interview with Staff Q (Associate Director of Nursing) on 10/7/24 at 2:30 PM, Staff Q stated the patient was confused and made comments earlier in the day that men in a boat had locked them up and hit them. Staff Q stated they did not make an incident report for Patient #11's allegations due to the patient's confusion and lack of evidence of injury on the patient's face.

During interview with Staff V (Director of Nursing) on 10/7/24 at 4:30 PM, Staff V was asked if any incident report was completed for Patient #9's allegation, they stated there was not. When asked if they felt that a report should have been filed, they stated that one should have been filed.