HospitalInspections.org

Based on a review of documentation and interview, the facility failed to ensure the patient right to be free from all forms of abuse or harassment, as evidence by staff members failing to appropriately report suspected abuse/neglect per facility policy.

Findings included:

Facility policy entitled, "PC 214 Abuse and Neglect Guidelines and Indications for Referral" stated in part,
"PROCEDURE: ...
3. Patient care personnel who suspect a presenting patient to be a victim of abuse, neglect or exploitation should immediately notify the charge nurse and the assigned Social Worker/Case Manager (if after hours, the assigned Social Worker/Case Manager on call) to facilitate communication with TDFPS ..."

Review of the medical record revealed Patient #1 had two episodes of potential abuse by a family member:

On the evening of 04/15/24, the patient's son restrained their arms to bed rail with bed linens, the linens were removed when discovered by staff, no injuries noted.
* Nursing staff that observed the son restrain the patient's arms on 04/15/24 failed to notify the social worker per facility policy. According to documentation by the social worker, they were notified of the incident on the afternoon of 04/16/24 by the nurse case manager. The social worker had to educate the staff member on the need to report the incident to Adult Protective Services (APS).
* It appeared nursing staff was unaware of their mandatory reporter status. On 04/16/24 at 1706 the social worker documented, "...SW asked nurse and charge nurse to inform the night bedside nurse to please make APS report. SW educated the Director that all nurses are mandatory reporters and need to make reports if they are witness to abuse or neglect. SW educated staff of option to call APS to make report or how to make report online..."
* According to documentation a report was made by the witnessing nursing staff on 04/17/24 at 0500.
* In interview on 05/07/24 the nurse witnessing the events of 04/15/24 stated they are now aware of their mandatory reporting status and how to file a report online (after being educated by their manager).

On the evening 04/17/24 the patient's son was heard yelling in the patient's room and proceeded to barricade himself in the patient's room, requiring removal by facility security and the local police department.
* The social worker made a report for the incident on 04/17/24 with APS on 04/18/24. Social worker note on 04/18/24 at 0818 stated in part, "...SW informed of overnight incident with patient and son." It is not clear how the social worker was notified about the event on 04/17/24. It is not documented whether the nurse witnessing the event on the evening 04/17/24 notified the social worker and charge nurse per policy. It does not appear the nursing staff that witnessed the events first hand on 04/17/24 made the report to APS.

In the 2 incidents above, the facility policy to report suspected abuse/neglect was not followed appropriately by nursing staff. It appears nursing staff is not aware of their role as mandatory reporters.

In interview on 05/07/24 the Quality Director confirmed the current facility policy does not clearly state mandatory reporter requirements for nursing staff. The current policy reads the "charge nurse and the assigned Social Worker/Case Manager (if after hours, the assigned Social Worker/Case Manager on call)" are to "facilitate communication with TDFPS" which does not provide direction to nursing staff to mandatoryily report and the process for filing a report with TDFPS.

The above findings were verified with staff members #1 and 2 on 05/07/24.