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Based on record review and interview the facility failed to immediately respond to allegations of caregiver abuse/misconduct and protect patients from further abuse while conducting ongoing investigations in 2 of 3 caregiver misconduct allegations reviewed (Pt #1 and 10), in a total sample of 3 caregiver misconduct allegations reviewed and failed to have a policy that delineated immediate steps that would be taken to protect patients in 1 of 1 abuse policies reviewed.

The facility did not take steps to immediately protect patients from abuse when an abuse allegation was reported in 2 of 3 allegations reviewed. See A-0145

The facillity policy does not delineate immediate actions that should be taken to protect patients when an abuse allegation is reported in 1 of 1 abuse investigation manuals reviewed. See A-0145

Based on record review and interview the facility failed to immediately respond to allegations of caregiver abuse/misconduct and protect patients from further abuse while conducting ongoing investigations in 2 of 3 caregiver misconduct allegations reviewed (Pt #1 and 10), in a total sample of 3 caregiver misconduct allegations reviewed and failed to have a policy that delineated immediate steps that would be taken to protect patients after an allegation of abuse in 1 of 1 abuse policy reviewed.
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Findings Include:

Review of the "Investigation Manual For Alleged Team Member Misconduct" last updated January 2023 revealed,
- "A formal investigation into alleged Team Member misconduct will be led by Human Resources (HR) Team (Team Member Relations) with support from other departments assisting in leading the investigation including Compliance...Legal, Quality and Regulatory, Risk Management..."
- "Upon the receipt of a report or detection of alleged misconduct, the receiving department shall conduct an initial inquiry to determine if an investigation is warranted. In any case involving known or suspected patient or team member harm, patient safety, risk management, public safety, and the site executive team should be notified immediately to determine whether the critical event response plan should be implemented."
- "Once the intake process is complete, the Team Member Relations Consultant (HR) will determine key departments and initiate a call to determine next steps with regards to the investigation."
- "Goals when investigating include: 1. Identify, pursue, and document all relevant facts, evidence, and witnesses...5. Make reasonable efforts to protect any alleged victim (s) and/or the organization from further harm both during and following completion of an investigation."
- "Team Member misconduct occurring outside of normal business hours, should be directed to the Team Member Relations (HR) team via an Urgent Intake Form..."

Per review of the facilities "Investigation Manual For Alleged Team Member Misconduct," there was no documentation addressing how the hospital will ensure all patients are kept safe immediately after being notified and while investigating allegations of caregiver abuse and misconduct.

Pt #1:

Review of Pt #1's medical record revealed Pt #1 was admitted to the inpatient unit of the hospital on 08/21/2024 at 5:48 PM with a diagnosis of Sepsis (blood stream infection) and Pneumonia (lung infection); Pt #1 was discharged home on 09/03/2024 at 1:34 PM.

Review of Pt #1's Discharge Summary dated 09/03/2024 at 1:01 PM revealed that Pt #1 was 47 years old with a past medical history significant for Quadriplegia (paralysis of all four limbs and the body from the neck down) status post a motor vehicle crash in June 2024.

Review of Respiratory Therapy (RT) C's progress note dated Sunday 09/01/2024 at 9:25 AM revealed, "Attempted respiratory protocol reassessment. (Pt #1) uncooperative and refusing any attempts. States 'you're making me angry and get out'. Will continue already established respiratory treatment plan."

Review of Registered Nurse (RN) G progress note dated 09/01/2024 at 10:00 AM revealed, "Writer was called into room by patient around 0930 (9:30 AM) and was informed that (Pt #1) had an incident with another staff member (RT C). Patient complaining of right eye pain post incident, no clear signs of trauma. MD (medical doctor) updated."

Review of the HR Teammate Relations Investigation Summary (Case 411503) revealed, "On September 1st, 2024 (no time)...a patient identified as (Pt #1), a quadriplegic being treated for hypoxia and pneumonia, reported being assaulted by a respiratory therapist during a routine procedure. The patient stated that while he was sleeping, a respiratory therapist...attempted to administer a treatment by forcefully inserting a device into (Pt #1's) mouth. When the patient resisted, the device was reportedly smashed into his face, causing pieces to fly around and strike (Pt #1) in the eye. The patient claimed that the therapist swore at (Pt #1) and then left the room abruptly."

Review of the HR Teammate Relations Investigation Summary (Case 411503) revealed, "Upon being questioned, (RT C) explained that he had indeed attempted to administer a breathing treatment but denied any physical aggression or contact beyond the mouth area. The situation escalated further when the patient's family members sought to confront the therapist, leading to (RT C) requesting an early end to (RT C's) shift." Per the Investigation Summary of the incident, "(Pt #1) was offered support, and it was agreed that (RT C) would no longer be involved in (Pt #1's) care."

Review of RT C's Hours Worked on 09/01/2024 revealed that RT C started work at 5:59 AM and ended work at 12:15 AM (2 hours and 45 minutes after RN G was notified of the incident) (RT C did not work again until 09/13/2024).

Review of Pt #1's HR Investigation Summary revealed the following timeline "Initial Planning Meeting" to discuss the with the team (HR, Risk, Legal, Public Safety, RT Manager, Director of Nursing, House Supervisor) was on 09/03/2024 (2 days after incident). The allegations were determined to be unsubstantiated and the investigation was documented as completed on 09/06/2024.

Per interview with RT Manager B on 10/10/2024 beginning at 9:20 AM, RT B stated that after Pt #1's allegations against RT C on 09/01/2024, RT C was removed from providing care for Pt #1, but was still providing care to other patients on the unit. Per RT Manager B, RT C voluntarily requested to end the shift due to alleged pressure from Pt #1's family; RT B confirmed that RT C did not leave due to being suspended at that time. When asked if staff should be providing care to patients when there are allegations of patient harm, RT B stated that if there are allegations of patient harm, staff should be removed from all patient care until the incident is investigated and next steps determined. RT B stated that the determination to suspend a staff member due to allegations of abuse is made with HR.

Per interview with RN G on 10/09/2024 beginning at 2:07 PM, RN G stated that after Pt #1 informed RN G of the allegations against RT C (9:30 AM), RN G reached out to the House Supervisor (HS I) but could not immediately get a hold of HS I. RN G stated that HS I reached out after about an hour and was notified of the allegations. Per RN G, HS I instructed RN G to write up an incident report. RN G stated that RT C continued to work with patients after the incident.

Per interview with House Supervisor (HS) I on 10/09/2024 beginning at 2:55 PM, HS I stated that Administrator On Call (DON D) responded to the incident on 09/01/2024 at approximately 10:30 AM. HS stated that the incident was escalated to the Administrator On Call (DON D) at approximately 11:30 AM (2 hours after incident reported); HS I stated that an Urgent Request was then submitted to HR. HS I stated that RT C was removed from Pt #1's care. HS I stated that RT C continued to provide care to other patients on the unit (after staff were notified of the allegations) until RT C voluntarily left at around 12:30 PM. HS I stated she did not receive direction from the DON to remove RT C from patient care, and stated that she "can not just suspend staff."

Per interview with Director of Nursing (DON) D on 10/09/2024 beginning at 3:15 PM, DON D stated that she was notified by HS I of the allegations against RT C on 09/01/2024 at approximately 12:15 PM (2 hours and 45 minutes later). DON D stated that she "originally thought the allegations were already looked into" and stated this should have been reported immediately. DON D stated that staff should follow the facility caregiver misconduct Investigation Manual. DON D stated that staff should send an "Urgent Request" to Teammate Relations (HR) when there are allegations of patient harm due to caregiver misconduct, HR will typically respond within 30 minutes and make a determination if staff member will be removed from patient care and suspended. DON D stated that it is acceptable for a staff member accused of patient harm to continue to provide care to other patients while the team is "fact finding" an allegation of patient harm.

Per interview with Human Resources (HR) F on 10/09/2024 beginning at 1:09 PM, HR F stated that caregiver misconduct allegations are relayed to HR either by Risk Management, Leader, or Urgent Notifications from staff. Per HR F, when notification is received, HR F will schedule an intake meeting with necessary staff (as per caregiver misconduct Investigation Manual). HR F stated that the accused teammate/staff member is usually suspended during the investigation process. Per HR F, if the teammate is not immediately suspended, the teammate is separated from the patient (accuser) and a "buddy system" is put into place until a determination is made if teammate should be suspended. Per HR F, HR did not receive an Urgent Request to respond to Pt #1's allegations because the House Supervisor did not check the "Imminent Danger" box to initiate an Urgent Request. HR F stated that RT C was suspended on 09/01/2024 at 4:30 PM.

Patient #10:

Review of Pt #10's History and Physical dated 04/29/2024 at 6:00 AM revealed, Pt #10 was admitted as an inpatient on 04/29/2024 at 1:46 PM with a chief complaint of nausea and vomiting; Pt #10 was discharged on 05/06/2024 at 2:48 PM.

Review of Patient Safety Event Form #PR-24-0126626 revealed that on 05/02/2024 at 5:58 PM, "(Pt #10) states that phlebotomist was too rough holding her arm down for lab draw this morning, and they wouldn't let go when (Pt #10) asked them to."

Review of the facility's response to Pt #10's Safety Event revealed the following:
-Email sent from Risk Manager K to Lab Manager O on 05/03/2024 at 10:18 AM, informing Manager O of this Safety Event.
-Email sent from Manager O to Phlebotomist O on 05/06/2024 at 7:57 AM asking Phlebotomist O for additional details about the event.
-Email sent from Phlebotomist O to Manager O on 05/06/2024 at 11:07 AM, explaining what occurred, denying the accusations and stating that Phlebotomist Q was also in the room and could attest to the event.
-Progress notes from Quality Coordinator R documenting interview with Phlebotomist Q, there was no documentation of the date and time of the interview.
-Investigation completed and unsubstantiated on 05/09/2024.

Review of the Pt #10's Safety Event file revealed there was no documentation of staff immediately escalating Pt #10's caregiver abuse/misconduct allegations to the leader, administrator on call, and HR to determine the immediate next steps for the investigation and ensure patient safety as per policy.

Per interview with Risk Manager J and Risk Manager K on 10/10/2024 beginning at 10:37 AM, while discussing Pt #10's Safety Event, Risk Manager J stated that there was no way to send an Urgent Request to HR to report caregiver abuse and misconduct allegations from the Safety Event reporting system. Risk Manager J stated that Pt #10's allegations should have been escalated to leader, then administrator on call, and then to HR to coordinate next steps. Risk Manager J confirmed that only Manager O and Risk Manager K were involved in reviewing Pt #10's caregiver abuse/misconduct allegations.