HospitalInspections.org

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Based on interview and record review it was determined the facility failed to protect 1 of 10 sampled patients (Patient 5) from physical abuse, failed to protect the patient from further potential abuse, and failed to investigate and report the incident of abuse according to facility policy. Findings include:

This survey was conducted following the receipt of a complaint alleging that facility staff had "placed the emergency call light cord around the neck" of a demented and combative patient while the patient was on the toilet. Facility investigation reports indicate that on the evening of 5/30/11 a CNA (Employee 12) reported to the Nursing Supervisor (Employee 13) that she had witnessed an incident of possible abuse of Patient 5.

Reportedly, an RN (Employee 4) had "placed the emergency call light cord around the neck" of a demented and combative patient (Patient 5)while the patient was on the toilet. Employee 4 had also allegedly told Patient 5 to "shut up."

Information from facility staff, including Employees 1 through 17, and review of facility investigation findings, reports and records determined that the incident had occurred as described. The facility failed to protect Patient 5 from an incident of physical abuse on 5/30/11.

Policy review further revealed the facility had several specific policies and procedures that addressed how such an incident was to be managed. Those policies included "Ethics, Rights, and Responsibilities," "Interpersonal Violence," and "Violence Free Workplace."

Those policies direct staff to "promptly and accurately report" all incidents and comply with all "mandatory reporting requirements." Interview and record review revealed that facility staff failed to implement those policies and procedures as planned.

Although Employee 12 had first reported the incident to the Nursing Supervisor (Employee 13 ) on 5/30/11, no further action was taken at that time. Employee 13 did not report the incident to another management representatives until 6/7/11.

Law enforcement or other State officials were not contacted as directed by policy. No actions were taken on 5/30/11 to protect Patient 5 from further incidents of potential abuse. Employee 4 was allowed to continue her scheduled work. She was placed on "suspension" on 6/8/11.

The facility also failed to ensure an investigation into the alleged incident was initiated in a timely manner. An investigation was not undertaken until 6/7/11. Although the facility has a variety of related policies, none of those policies address a written procedure for investigating allegations of abuse, or include methods to protect patients from abuse during the investigation.

The facility failed to protect Patient 5 from an incident of abuse, and failed to implement policies and procedures on the identification, investigation and reporting of such incidents.

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