HospitalInspections.org

Based on review of documents and staff interview it was determined the hospital failed to ensure the patient's right to be free from all forms of abuse or harassment during the investigation of an allegation related to possible patient abuse by an employee. The hospital allowed the employee to return to work and provide direct patient care prior to the completion of the investigation. This has the potential to negatively affect the care and safety of all patients by the hospital not removing the alleged abuser from the patient care area until the investigation has been completed. Findings include:

1. During an interview in the morning of 3/8/10 and the afternoon of 3/9/10 with the Chief Operating Officer (COO), Director of Nursing (DON) and the Hospital Counsel indicated there was a process followed when investigating allegations of abuse. The process included removing the employee from patient care; however, they were unable to provide a written policy or procedure relative to the process. The employee in question was called at home on 3/4/10 and again on 3/5/10 with a message left for her to return the call made by the DON. On 3/5/10, prior to leaving work, the DON called the floor and asked when the employee was scheduled to return to work and was informed, not until 3/8/10. It was discovered that on 3/6/10 (Saturday) the employee in question returned to work and was assigned to direct patient care prior to the completion of the investigation(the allegation of abuse occurred on 3/3/10). The Charge Nurse instructed the employee not to enter the complaint patient's room.

Based on review of documents, medical records and staff interview it was determined the hospital failed to ensure the medical staff followed the Bylaws, Rules and Regulations of the medical staff in four (4) of ten (10) medical records reviewed for physician authentication of verbal/telephone orders. This has the potential to negatively affect the care of all hospitalized patients, by the physician not intercepting and correcting a potential transcription error. Findings include:

1. Hospital Bylaws, Rules and Regulations last reviewed/revised 1/2009, states in part: "All verbal and telephone physician orders must be dated, timed and signed by the physician within 48 hours."

2. Patient #1 was admitted to the hospital on 3/1/10. Physician verbal orders given on 3/3/10, 3/5/10 and 3/6/10 remain unsigned as of 3/9/10.

3. Patient #4 was admitted to the hospital on 3/5/10. Physician verbal orders given on 3/5/10 remain unsigned as of 3/9/10.

4. Patient #6 was admitted to the hospital on 3/6/10. Physician verbal orders given on 3/7/10 remain unsigned as of 3/9/10.

5. Patient #9 was admitted to the hospital on 3/3/10. Physician verbal orders given on 3/7/10 remain unsigned as of 3/9/10.

6. These medical records were reviewed with the Clinical Coordinator of the third floor in the morning of 3/9/10 and she agreed with these findings.