HospitalInspections.org

Based on facility documents, facility policies, record review and interview, the facility failed to ensure the patients' right to be free of abuse were promoted.

The findings included:

1. The facility failed to protect all patients from abuse during alleged abuse investigations, follow their policy for interviewing during investigations, and ensure all allegations of abuse and/or neglect were investigated.

Refer to A 145

Based on facility documents, facility policy, record review and interview, it was determined the facility failed to ensure patients' were free from all forms of abuse during 1 of 3 (Allegation #1) and failed to investigate 1 of 3 (Allegation #3) allegations of abuse.

The findings included:

1. Review of the facility's "Reporting of Abuse and Neglect" policy documented, "...Abuse or Neglect - the infliction of physical pain, injury, or mental anguish, or the deprivation of services by a caretaker that are necessary to maintain the health and welfare of an adult or a situation in which an adult is unable to provide or obtain services that are necessary to maintain that person's health or welfare...Reporting...Employees will report suspected adult or child abuse...or neglect to Social Services...".

The facility's "Incident Reporting and Response" documented, "...When any allegation of patient abuse/neglect occurs, the following should occur...The Director/Designee of the area should follow up...to ensure that the particular caregiver is not assigned to re-assigned to the patient...in consultation with Employee Relations should determine if suspension is appropriate...The Director/Designee should interview other patients and employees to ensure no similar complaints or observations have been identified...".

Review of the facility's "Standard Conduct" Human Resource policy documented, "...PROPER PATIENT CARE AND PROPER PERSONAL DEMEANOR...This includes, for example...Any form of abuse or neglect of a patient or the failure to be attentive to possible patient needs...Abusive or discourteous conduct or use of...derogatory...or loud language...Verbal or other harassment...".

2. Medical record review revealed Patient #1 was admitted to the hospital on 7/17/13 to the Trauma Intensive Care Unit (TICU). Record review revealed the patient was in a motor vehicle crash and sustained a Subdural Hematoma, Subarachnoid Hemorrhage and multiple fractures.

Review of facility documents revealed an allegation of abuse was reported related to an incident that occurred on 7/28/13. The incident, Allegation #1, alleged that RN #1 was abusive to Patient #1.

Review of the facility's investigation of Allegation #1 documented on 7/28/13 RN #1 was taking care of Patient #1. The mother of Patient #1 reported that RN #1 was "abusive" to Patient #1. The mother witnessed and reported that RN #1 grabbed Patient #1 "by the back of the c-collar and pulled down hard on it while pushing hard in his chest thrusting...[Patient #1] down to the bed..." The mother then reported Patient #1 was trying to get up again and RN #1 "...then pushed with both of his hands very forcefully on...[Patient #1's] chest and pinned him down to the bed yelling to the patient he was no going to have this tonight this is ridiculous...".

During an interview in the conference room on 10/28/13 at 3:20 PM, the Nurse Manager (NM) for the unit stated she talked with Patient #1's mother. The NM stated the patient's mother reported RN #1 looked frustrated and "used both hands to the chest and shoved him in the bed and pinned him down. [RN #1 then said] This is ridiculous, I'm not going to have this tonight. [RN #1] later pulled the collar...". The NM stated during an allegation of abuse investigation, "...We let the accused continue to work, just don't assign them to the patient [alleged victim]".

During an interview in the conference room on 10/29/13 at 9:00 AM, the Patient Care Coordinator (PCC) was questioned regarding the 7/28/13 incident. The PCC stated the accused RN #1, "...didn't show any emotion when I talked with him. I told him this was pretty severe...". The PCC was questioned regarding if the employee was suspended during an allegation of abuse investigation. The PCC stated, "Depends on what it is...usually remove the staff out of the situation and reassign them [with a family reported]...If you see an employee hit a patient they would be taken out and suspended...". In this situation RN #3 "reassigned him [RN #1]" to other patients on the same unit.

Review of the working schedule revealed RN #1 was assigned to other patients and worked on 7/29/13 the night after the 7/28/13 allegation of abuse was reported. This was verified by the PCC and Nurse Manager.
There was no documentation the facility interviewed other patients or patient representatives and employees in accordance with facility policy.
The employee was terminated on 8/1/13 for "Improper interaction with Patient".

During a telephone interview on 11/18/13 at 1:30 PM Patient #1's mother stated the patient was trying to get up from the bed and RN #1 said, "This is ridiculous. He [RN #1] grabbed the back of his [Patient #1's] collar and pulled him back down on the bed. [Patient #1's name] tried to get back up again and the nurse [RN #1] put both hands on his shoulders and shoved him back down on the bed. He [RN #1] was very forceful...".

3. Medical record review for Patient #2 revealed the 17 year old was admitted to the hospital on 6/4/13. Record review revealed the patient had sustained gun shot wounds to the head, presented to the emergency department and admitted to TICU.

During an interview in the conference room on 10/28/13 at 10:15 AM the Interim Director of Quality (IDQ) reported Patient #2 had alleged RN #1 had abused him/her on 7/5/13, Allegation #2.

Review of facility documents revealed Patient #2's mother reported on 7/5/13 the patient indicated RN #1 hit him/her on the chin. During the facility's investigation of Allegation #2 the patient's mother stated "...she saw another nurse [other than RN #1] being 'mean' to a patient across the hall in TICU", Allegation #3.

When questioned about prior allegations of abuse, the NM stated a couple of weeks ago there was an allegation of abuse by Patient #2 against RN #1 but couldn't "sustain [substantiate] it".

On 10/28/13 at 3:30 PM when the surveyor asked for the investigation of Allegation #3, the IDQ stated Allegation #3 of the nurse being "mean" to a patient across the hall had not been investigated.

During a telephone interview on 11/18/13 at 1:10 PM the mother of Patient #2 was asked about the incident with the nurse being "mean" to another patient across the hall. Patient #2's mother stated a female nurse was "yelling and screaming" at the patient across the hall to "get your leg back in that bed, don't you dare do that".

4. On 10/29/13 at 2:40 PM when questioned if all abuse was reported to Social Services as indicated in the facility's Abuse policy, the IDQ stated the policy only referred to the reporting sexual abuse. There was no documentation the alleged abuse had been reported to Social Services.

During an interview in the conference room with the Chief Medical Officer (CMO), Interim Director of Quality (IDQ) and the Chief Nursing Officer (CNO) on 10/29/13 at 3:00 PM, the IDQ verified there was nothing in the facility's policy and procedures that addresses the protection of the patients during an allegation of abuse investigation. The CMO stated they would be immediately addressing the patient's protection.