HospitalInspections.org

Based on reviews of policies and interview with staff, it was determined the hospital failed to have a comprehensive written policy for the investigation of an abuse or neglect allegation. This has the potential for the facility to not adequately investigate or document an allegation of abuse or neglect.

Findings include:

1. Review of the hospital's policy "Adult Institutional Abuse", originating 1/23/2005, revealed the policy failed to include information on the definition and/or identification of "neglect". The policy also failed to outline in detail how an investigation into an allegation of abuse or neglect will take place including naming specific job titles of persons ultimately responsible for the investigation or how each patient will be protected during such investigation.

2. The Regulatory Readiness Manager and the Risk Manager were interviewed in the morning on 12/28/2011 relative to the policy and the hospital's current procedures for investigating and documenting allegations of abuse or neglect. They discussed the hospital's current expected procedure for investigating and documenting an investigation into an allegation of abuse or neglect, and the hospital's measures for protecting patients during those investigations. Although the hospital is performing the required aspects of investigation of an allegation of abuse and the protection of patients during an investigation, the written policy failed to adequately outline the hospital's expectation for the investigation. They concurred with the findings.