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Tag No.: A0144
Based on review of policy and procedures, documents, personnel files and interviews it was revealed Senior Charge Nurse #1 failed to follow the discipline policy to ensure patient care is rendered in a safe setting. This failure has the potential to place all patients at risk for emotional health and discomfort.
Findings include:
1. A review of the "Progressive Discipline Policy," revised 08/31/15, states in part: "Disciplinary action may call for any of the following written steps: Verbal Warning, Written Warning, Suspension or Probation, Termination ... Behavior relating to patients, visitors, and volunteers such as: Offense: Discourteous treatment of patients, visitors or volunteers. First offense: Written Warning, second offense: Suspension or Probation, third offense: Discharge."
2. An interview was conducted with certified nurse aide (CNA) #1 on 11/12/19 at approximately 3:14 p.m. When asked if she took care of patient #1 and made the comments reported by the family, she stated in part: "The family was very demanding and rude ... I said let's put her in Trendelenburg, it was like lifting a house. ... I knew it was wrong and it hurt her feelings."
3. An interview was conducted with the Director of Quality and Risk Management on 11/12/19 at approximately 1:40 p.m. When asked if the discipline policy was followed she stated in part: "I asked Human Resources (HR) if Senior Charge Nurse #1 called them about disciplinary actions for CNA #1. She did not. HR said they would have told her to follow their policy."
5. An interview was conducted with Senior Charge Nurse #1 on 11/12/19 at approximately 1:50 p.m. When asked if she received a complaint from patient #1 about a comment made by CNA #1 she stated in part: "The next day ... CNA #1 came in and reported the incident. ... The incident was reported by RN #2. I did verbal counseling with her ... I was not aware of the disciplinary policy. ... If I had known, I would have called Human Resources (HR). They would have recommended to follow the policy. Then I would have followed the policy."
6. An interview with the Director of Quality and Risk Management was conducted on 11/13/19 at approximately 8:45 a.m. When asked if Senior Charge Nurse #1 should have followed the "Progressive Discipline Policy," she concurred the Senior Charge Nurse should have called HR and would have been directed to follow the policy.