HospitalInspections.org

Based on interview and document review, the facility failed to ensure nursing staff followed the facility's abuse prohibition policy and procedure when suspected abuse was not reported or addressed in a timely manner for 1 of 1 patient (P1). This deficient practice had the potential to affect all 8 current and future patients.

Findings include:

Review of the January 2022, Vulnerable Adult (VA) Maltreatment Policy identified it was the responsibility of the facility to report suspected or actual abuse, neglect, misappropriation of property/financial exploitation and injuries of unknown origin, suspicious of nature, of vulnerable adults immediately and as mandated by law and indicated all personnel must comply with applicable state and local laws regarding incidents of actual or suspected maltreatment. The policy identified a process to implement upon suspicion or reports of potential abuse, neglect, which included licensed personnel were to report to the Minnesota Adult Abuse Reporting Center (MAARC) and complete an internal report to the supervisor of the personnel. An investigation was to be completed to include interviewing other patients and staff, review patients medical record with protection of the patient and others at risk, which included suspension of the suspected employee, pending the outcome of the investigation.

Review of P1's medical record, identified P1 was admitted to the facility for acute care related to alcohol withdrawal on 12/29/21, and had been discharged to a skilled nursing facility on 1/12/22. P1's medical record identified he was alert, oriented and was able to verbalize his needs and wishes.

Review of the 1/10/22, Employee Event Form dated identified on 1/8/22 at 7:00 p.m., nursing assistant (NA)-A had been observed entering P1's room and offered to wash P1 before bed in which P1 had declined. NA-A had removed P1's incontinent brief, exposing his private area and washed his private area despite P1 having declined assistance. The report revealed the witness and author of the report, registered nurse (RN)-A, had been present throughout the interaction and had donned a clean incontinent brief on P1 following the incident. The report identified RN-A had been "uncomfortable and embarrassed" for the patient. The report did not identify if P1 was asked how he felt about the incident, or any other information on what steps were taken with the NA to prevent future incidents with P1 or other patients.

During an interview on 1/19/22, at 10:45 a.m. the acute care nurse supervisor (NS)-A stated she had been made aware of the incident between P1 and NA-A on 1/10/22, via email, two days following the incident. NS-A stated upon being notified of the incident on 1/10/22, she spoke with RN-A who witnessed the event and also with P1. NS-A indicated upon her interview with P1, he never indicated he felt unsafe or felt he was abused by NA-A. NS-A stated P1 had firmly stated he did not want NA-A to work with him again and felt NA-A did not listen to what he said. NS-A stated when she spoke with RN-A, she had indicated she felt P1 had been "emotionally abused" by NA-A. NS-A confirmed she spoke with NA-A on 1/10/22, regarding the incident and removed NA-A from the schedule on 1/11/22, following human resources review. NS-A stated she would have expected to be notified immediately of the incident , and would have wanted a report filed to the State Agency (SA) completed at that time. NS-A indicated NA-A should have been removed from providing patient care until an investigation was completed. NS-A confirmed NA-A worked the remainder of her shift on 1/8/22, provided patient care again on 1/9/22 and 1/10/22.

During an interview on 1/19/22, at 1:00 p.m. RN-B indicated she had been working on 1/8/22, and been not been aware of the above incident until two days following the incident.

During an interview on 1/19/22, at 1:35 p.m. the facility social worker (SW) stated she been made aware of the incident with P1 and NA-A, when she had spoken with P1 prior to his discharge from the facility on 1/12/22. The SW indicated P1 had told her he had spoken with the nurse supervisor regarding the incident. He did not want the NA to work with him again, indicated he felt the NA did what she wanted. SW indicated at no point in time had P1 indicated he felt abused. SW indicated she had not specifically asked P1 how or if the incident made him feel or if he felt unsafe.

During an interview on 1/19/22, at 2:00 p.m. NA-A confirmed she and RN-A had provided cares for P1 on 1/8/22, and indicated P1 had yelled at her briefly for not wanting cares completed. NA-A indicated she had encouraged P1 to allow her to change his incontinent brief, which he had agreed to. She indicated she was not aware of any concerns with cares she provided to P1 until she was contacted by the nursing supervisor on 1/11/22. NA-A stated at that time she was placed on paid administrative leave while the supervisor investigated the event.

During a telephone interview on 1/19/22, at 5:10 p.m., RN-A confirmed she had worked on 1/8/22, and had witnessed the interaction between P1 and NA-A. RN-A stated on that day, she had assisted P1 with toileting, was walking him back to his bed from he bathroom when NA-A entered the room. RN-A indicated NA-A immediately asked P1 to get ready for bed, and offered to change his incontinent brief. She indicated P1 declined, and NA-A removed his incontinent brief, washed his genitals while P1 verbalized for her to stop. RN-A indicated she felt very uncomfortable and felt P1 had been emotionally abused when NA-A refused to stop providing cares when P1 asked her to. RN-A stated she "calmed" P1 down and assisted him to bed. P1 had indicated he felt mistreated and had requested not to have NA-A assist him with any future cares. RN-A indicated she did not stop NA-A from providing cares and did not speak to NA-A about her concerns following the incident. Following the incident, she spoke with her colleagues and the charge nurse who encouraged her to contact the nurse supervisor by email. RN-A confirmed she had notified the nurse supervisor on 1/10/22 via email, two days following the incident. RN-A confirmed she had not completed an internal incident report and had not reported her concerns of patient abuse to the MAARC system.

During an interview on 1/20/22, at 8:14 a.m. RN-C stated she had worked as a charge nurse on 1/8/22, and had been notified of the incident between NA-A and P1 by RN-A. RN-C stated she had been notified P1 had declined perineal cares, and NA-A had provided cares against P1's wishes. RN-C stated she had directed RN-A to contact the nurse supervisor via email and to complete an internal incident report. RN-C indicated she was not under the impression the incident had required a SA report. RN-C stated she had not spoken to NA-A or P1 regarding the incident, and NA-A continued to work the rest of her shift, until 10:30 that night.

During a telephone interview on 1/20/22, at 1:30 p.m. the director of patient services indicated he would have expected the nursing staff to have implemented the policy for abuse. He indicated he would be holding a meeting with the nursing staff to provide education on the facility's process for abuse prohibition.