HospitalInspections.org

Based on interview, record review and policy review, the facility failed to:
- Immediately remove staff from patient care after two allegations of staff to patient abuse were reported (Patient #11 and #13) of two abuse allegations reviewed (A-0144);
- Adequately investigate two allegations of staff to patient abuse (Patient #11 and #13) of two allegations of abuse reviewed (A0145);
- Complete a physical examination of one patient (#11) of two patients reviewed following an allegation of abuse (A0145); and
- Ensure that staff were immediately educated or re-educated about abuse, including the steps to take if they witnessed abuse, after the substantiated allegation of staff to patient abuse of one patient (#11) of one substantiated allegation of abuse reviewed (A0145).

These failures resulted in the overall non-compliance with 42 CFR 482.13, Condition of Participation: Patient's Rights. The cumulative effect of these systemic practices had the potential to place all patients at risk for their safety, also known as Immediate Jeopardy (IJ).

On 04/06/17, at the time of survey exit, the facility provided an immediate Plan of Correction sufficient to remove the IJ by implementing the following:
- Immediate education to all staff with position responsibilities that placed them in direct patient contact as
related to the recognition and prevention of abuse and neglect, the steps to take if abuse and/or neglect were witnessed, and reporting procedures.
- Immediate, frequent and ongoing monitoring of staff's validation of understanding of abuse and neglect education, through verbal assessment and scenarios on all shifts and all units until compliance is achieved and maintained.
- Inclusion of education into the Annual Mandatory Learning Objectives, hospital orientation and nurse residency program, as related to recognition and prevention of abuse and neglect, the steps to take if abuse and/or neglect were witnessed, and reporting procedures.
- Immediate education to supervisors, managers and directors regarding the steps to take immediately, and throughout the investigation process, when an allegation of abuse and/or neglect were reported.

Based on interview, record review, and policy review the facility failed to ensure that patients' rights were provided and explained in a language or manner that patients could understand for two patients (#4 and #14) of two Limited English Proficiency (LEP) patients reviewed. This failure could not allow patients to exercise their rights and placed patients at risk for substandard care and could potentially prevent the patient, or their representatives, from being involved in their care. The system treats approximately 150 non-English speaking patients per month. The facility census was 421.

Findings included:

1. Record review of the facility's policy titled, "Provision of Meaningful Communication for Persons with Limited English Proficiency," dated 03/24/17, showed the following directive for staff:
- The facility will provide interpreting and translation services for LEP patients and/or their authorized representatives in order to ensure access and equal opportunity to participate in health care services without cost to the person being served.
- Staff should request an interpreter from Language Services for inpatients.
- Staff should find out what language the LEP patient spoke, document the language the patient spoke, and contact Language Services for review and to provide interpreters for subsequent visits for outpatients.
- The use of family members, friends, or other untrained individuals is highly discouraged due to reasons of competency of interpretation, and confidentiality, privacy and conflict of interest.

2. Record review of the facility's undated document provided titled, "Patient Rights and Responsibilities", showed patients had the right to be provided information in a way they could easily understand.

3. Record review of Patient #4's Admission Note, dated 04/04/17, showed:
- She presented on 04/04/17 at an off-site Emergency Department (ED) with a chief complaint of lower extremity leg pain, was treated and sent for further evaluation to the on-site ED.
- She was a 67 year old non-English Speaking female.
- She was admitted on 04/04/17.

During an interview on 04/04/17 at 10:55 AM, with use of a video interpreter service because the patient spoke Chuukese (Micronesian language), Patient #4 stated that she did not receive her patient rights and if she had a complaint or grievance she would tell someone, but was not sure exactly who to notify. She stated that the staff used her granddaughter to interpret for her.

Record review of Patient #4's Condition of Service (a consent form) showed that by signing the documents the patient had a list and knew their patient rights and responsibilities as a patient. Patient #4's name was hand written above the patient representative area and it was undated.
The facility had the patient sign that the patient knew their patient rights when the patient rights were not explained to the patient in a language and manner they could understand.

4. Record review with concurrent interview on 04/06/17 at 9:30 AM showed the document of Patient Rights and Responsibilities written in Spanish and English. Staff LL, Manager of Patient Admissions for the main campus facility, stated that Spanish and English were the only languages in which the Patient Rights and Responsibilities were written.

During an interview on 04/06/17 at 10:15 AM, Staff ZZ, Patient Service Representative for the off-site ED, stated that:
- She will ask if the patient wants a copy of their patient rights (in English or Spanish if the patient was Spanish speaking). She explained the document showed their patient rights and responsibilities while the patient was in the hospital. She then turned the document over and pointed to the steps mentioned in the document and said these were the steps that explained how a patient could file a complaint or grievance.
- This was the process she went through with Patient #4's daughter (who spoke English) and the patient nodded her head (as if to understand). She did not read the Patient Rights and Responsibilities to the patient.
- She was not sure how an LEP patient would read the Patient Rights and Responsibilities if given to them in English when the patient did not speak English.

5. Record review of Patient #14's Admission Note showed she was admitted on 04/03/17 to the labor and delivery department due to being in labor (the process of childbirth) and was an LEP.

During an interview on 04/05/17 at 9:15 AM, with use of a video interpreter service because the patient spoke Swahili, Patient #14 stated that the staff had not read her patient rights to her and she would not know what to do if she had a complaint or grievance.

During an interview on 04/04/17 at 10:42 AM, Staff AA, Patient Service Representative (in the clinics), stated that she used the phone interpreter service to explain what the Patient Rights and Responsibilities were to Patient #14, but did not read them to her.

Record review of Patient #14's Condition of Service showed that by signing the document the patient had a list and knew their patient rights and responsibilities as a patient. Patient #14's unreadable mark and or name were hand written, but there was no date.
The facility had the patient sign that the patient knew their patient rights when the patient rights were not explained to the patient in a language and manner they could understand.

During an interview on 04/04/17 at 1:30 PM, Staff Q, Manager of Volunteer and Patient Support Services, stated that family were not to interpret. The facility had a phone system, a video system, and actual interpreters for Spanish and Arabic speaking patients. She thought the patient rights were read to the LEP patients.

During an interview on 04/06/17 at 10:45 AM, Staff MM, Coordinator of Ambulatory Business Services, stated that the clinics had phone interpreter services and some had video interpreter services available and were not to use family or friends for interpreters. The staff were to offer patient rights to the patient in English and to explain the patient rights, but were not expected to read the whole form. She was unable to answer how LEP patients would understand their patient rights if they received the document of Patient Rights and Responsibilities in English and the document was not read to them.

During an interview on 04/06/17 at 11:00 AM, Staff E, Director of Patient Access at the main campus facility and the off-site campus, stated that the staff had phone interpreter services, video interpreter services, or actual interpreters available as needed to interpret for LEP patients. The staff reviewed the Patient Rights and Responsibilities with the patient and if the patient wanted more information, the document was provided. She stated that she could not speak for patients, but if she was a LEP patient and her rights were not read to her, she would not understand them.

Based on interview and record review, the the facility failed to immediately remove staff from patient care after two allegations of staff to patient abuse of two patients (#11 and #13) were reported, of two abuse allegations reviewed. This failure created an unsafe environment, and could affect all patients. The facility census was 421.

Findings included:

1. Although requested, the facility failed to provide a policy related to the immediate removal of a staff member who was alleged to have abused or neglected a patient.

2. Record review of a PSN (Patient Safety Network, electronic complaint reporting system) report 01/16/17, showed that on 01/16/17 (estimated to have occured at approximately 3:30 AM, per various documented medical record entries), Staff NN, Contracted Registered Nurse (RN), threatened to call security and have Patient #13 tied down (placed in restraints), after the patient refused the insertion of a Naso-gastric tube (NG tube, plastic tube inserted through the nose, and passed into the stomach, to remove gastric contents or administer medication or nutrition). The patient then became agitated, and Staff NN called for assistance, and the patient was physically held down by patient care staff and then placed in restraints.

During an interview on 04/04/16 at 4:53 PM, Staff T, Care Team Assistant - Clinical (CTA-C), stated that he completed the PSN report that alleged Staff NN abused Patient #13 on 01/16/17. Staff T stated that he contacted his charge nurse and House Manager (Nursing supervisor who oversees nursing services during times that administration are and are not present) immediately and reported the incident, but Staff NN continued to work and provided care for Patient #13 as well as other patients for the remainder of her shift. Staff T added that he was not aware staff alleged to have abused a patient should be immediately removed from patient care.

3. Record review of "Time Detail" Report (timekeeping records that show clock in and out times), showed that Staff NN worked until 8:07 AM on 01/16/17 (approximately four and one half hours after the alleged abuse occurred), and continued to work approximately 36 hours per week until her contract ended on 02/17/17.

4. Record review of a PSN report dated 02/25/17 at 3:16 AM, showed that on 02/25/17:
- Patient #11 had been admitted after an overdose, and was "extremely confused and not steady on her feet".
- Staff AAA, Contracted RN, became aggressive with and cussed at Patient #11 (estimated to have occured at approximately 1:00 AM, per various documented medical record entries).
- Staff AAA attempted to pull on Patient #11, which appeared to scare the patient.
- Staff AAA continued to be aggressive with Patient #11, and said to her, "go to bed on your own or do I need to make you".
- Staff AAA shook Patient #11 by the shoulders and then grabbed the patient by the front of her gown and wrist, and drug the patient across the room and "flung her onto the bed".
- Patient #11 began crying and shaking.
- Staff AAA was allowed to continue to work (three additional shifts, per timekeeping records) until supervisory staff reviewed the PSN.

During an interview on 04/05/17 at 10:08 AM, Staff WW, CTA-C stated that:
- She completed the PSN report the day of the incident, which occurred in the early morning hours of 02/25/17.
- She felt Staff AAA abused Patient #11.
- Staff AAA continued to work the remainder of the shift, and provided care to Patient #11 as well as other patients.
- She was not aware staff alleged to have abused a patient should be immediately removed from patient care.

During an interview on 04/05/17 at 9:05 AM, Staff XX, RN (a second witness to the alleged abuse of Patient #11), stated that:
- Patient #11 was restrained because she was very confused and had a tendency to wander.
- Patient #11 vomited, and when the patient was to be cleaned up, Staff AAA pulled Patient #11 by her restraints to get the patient out of bed.
- That Staff AAA stated to Patient #11 when she began to wander, "You will get back [in bed] or I will drag you back to bed. Those are your options".
- That Staff AAA then cursed at the patient, something like, "I'm not fucking with you anymore".
- When Patient #11 refused to go back to bed, Staff AAA drug the patient by her restraints and gown, and then pushed her onto the bed.
- She believed Staff AAA had abused Patient #11.
- She was not aware staff alleged to have abused a patient should be immediately removed from patient care.

5. Record review of "Time Detail" Report, showed that Staff AAA worked:
- 02/25/17 (after the allegation of abuse at approximately 1:00 AM) until 7:56 AM (approximately eight hours after the alleged abuse occurred);
- 02/25/17 from 7:02 PM until 02/26/17 at 7:48 AM;
- 02/26/17 from 7:02 PM until 02/27/17 at 7:41 AM; and
- 02/27/17 from 6:58 PM until 02/28/17 at 7:47 AM.
The Time Detail Report showed that Staff AAA worked the remainder of the shift, and continued to work three 12 hour shifts after she was alleged to have abused Patient #11.

During an interview on 04/04/17 at 2:05 PM, Staff K, DON, stated that the PSN report submitted by Staff WW, CTA-C, was not reviewed for five days after it was completed, and added that Staff AAA continued to work after she was alleged to have abused Patient #11.

Based on interview, record review and policy review, the facility failed to:
- Adequately investigate two allegations of staff to patient abuse (Patient #11 and #13) of two allegations of abuse reviewed;
- Complete a physical examination of one patient (#11) of two patients reviewed following an allegation of abuse; and
- Ensure that staff were immediately educated or re-educated about abuse, including the steps to take if they witnessed abuse, after the substantiated allegation of abuse of one patient (#11) of one substantiated allegation of patient abuse reviewed.
These failures placed all patients at risk for abuse. The facility census was 421.

Findings included:

1. Record review of the facility's policy titled, "Leadership - Patient Safety Event Reporting," dated 05/20/15, showed:
- The Patient Safety Network (PSN, electronic complaint reporting system) resolution was the ultimate responsibility of the assigned departmental manager.
- The departmental manager would review reports in the PSN in a timely manner of receipt.
- The departmental manager would implement appropriate corrective action.

2. Record review of the facility's undated reference titled, "Conducting an Effective Internal Investigation," showed interval investigations would be:
- Investigated promptly;
- Thorough and factual;
- Complete and well documented; and
- Completed and appropriate action taken within days of a complaint.

3. Record review of a PSN report dated 01/16/17, showed Staff NN, Contracted Registered Nurse (RN) threatened to call security and have Patient #13 tied down (placed in restraints), after the patient refused the insertion of a Naso-gastric tube (NG tube, plastic tube inserted through the nose, and passed into the stomach, to remove gastric contents or administer medication or nutrition). The patient then became agitated, and Staff NN called for assistance, and the patient was physically held down by patient care staff, and placed in restraints.

During an interview on 04/04/16 at 4:53 PM, Staff T, Care Team Assistant - Clinical (CTA-C), stated that:
- He completed the PSN report that alleged Staff NN abused Patient #13.
- The alleged abuse occurred prior to other staff entering Patient #13's room, and that he was the only staff member who witnessed the abuse.
- The incident occurred in the early morning hours or 01/16/17, that he contacted his charge nurse and House Manager (Nursing supervisor who oversees nursing services during times that administration are and are not present) immediately, and reported the incident.
- He was never interviewed about the alleged abuse report.
- He had not received recent education related to abuse, and did not know staff alleged of abuse should be immediately removed from patient care.

During an interview on 04/05/17 at 8:55 AM, Staff NN, RN, denied that she threatened to call security and have Patient #13 tied down. Staff NN stated that Patient #13 escalated out of control and was a harm to herself, and so Staff NN called for additional staff assistance, who physically held the patient down and restrained the patient by her arms and legs. Staff NN stated that the patient was restrained approximately 45 minutes when a doctor and charge nurse came in and took the restraints off, because the physician said the patient "didn't need them", and then "reassured her [the patient] that we weren't going to do the tube [NG tube]". Staff NN stated that at 6:30 AM that same morning, the patient "begged me to put the tube in" but Staff NN refused to do it. "I told her that I was not going to go there with her".

During an interview on 04/06/17 at 3:38 PM, Staff K, Director of Nursing (DON) stated that:
- She did not interview Staff T, CTA-C because she "kept missing him";
- She determined the allegation that Staff NN had abused Patient #13 was unsubstantiated (not true) based only on her interview with Staff NN, the alleged perpetrator (person alleged to have abused);
- She rounded (spoke with to obtain information) on day shift staff (the allegation occurred during night shift) who reported that Patient #13 would have periods of calm and then have "flare ups", which made her "comfortable with the fact that there was no abuse"; and
- That the investigation was not complete, "I wish that I had done a better job", "I wish that I had better notes" and "I agree that I could have done more".

4. Record review of a PSN report dated 02/25/17, showed:
- Patient #11 had been admitted after an overdose, and was "extremely confused and not steady on her feet".
- Staff AAA, Contracted RN, became aggressive with and cussed at Patient #11.
- Staff AAA attempted to pull on Patient #11, which appeared to scare the patient.
- Staff AAA continued to be aggressive with Patient #11, and said to her, "go to bed on your own or do I need to make you".
- Staff AAA shook Patient #11 by the shoulders and then grabbed the patient by the front of her gown and wrist, and drug the patient across the room and "flung her onto the bed".
- Patient #11 began crying and shaking.
- Staff AAA was immediately removed from the schedule after the PSN was received and witnesses to the event were contacted to collaborate the PSN accounting of the event.

5. Record review of Patient #11's medical record showed no documentation that a physician was notified of the alleged abuse, and no documentation that an examination occurred immediately following the alleged abuse.

During an interview on 04/05/17 at 10:08 AM, Staff WW, CTA-C stated that:
- She completed the PSN report.
- Patient #11 was confused and tried to walk out the door, when Staff AAA grabbed the patient by her shoulders, and then cussed at her.
- Staff AAA said something like, "You either need to get back in bed or I will put you back into bed" or "Go to bed on your own or do I need to make you".
- Staff AAA then shook the patient in a more aggressive manner, which agitated the patient.
- Staff AAA then grabbed the patient's gown, and grabbed her arm, and drug her forward across the floor, and tossed her back into the bed.
- The patient started crying and was clearly upset.
- She (Staff WW) moved between Patient #11 and Staff AAA, and Staff AAA walked out.
- She felt Staff AAA abused Patient #11.
- She had not received education related to abuse since the incident.

During an interview on 04/05/17 at 9:05 AM, Staff XX, RN (a second witness to the alleged abuse of Patient #11), stated that:
- Patient #11 was restrained because she was very confused and had a tendency to wander.
- Patient #11 vomited, and when the patient was to be cleaned up, Staff AAA pulled Patient #11 by her restraints to get the patient out of bed.
- That Staff AAA stated to Patient #11 when she began to wander, "You will get back [in bed] or I will drag you back to bed. Those are your options".
- That Staff AAA then cursed at the patient, something like, "I'm not fucking with you anymore".
- When Patient #11 refused to go back to bed, Staff AAA drug the patient by her restraints and gown, and then pushed her onto the bed.
- She believed Staff AAA had abused Patient #11.
- She was not interviewed about the allegation of abuse.
- She had not received abuse education since the allegation of abuse.

During an interview on 04/04/17 at 2:05 PM, Staff K, DON, stated that:
- The PSN report of Staff AAA's alleged abuse toward Patient #11 was not reviewed for five days after the PSN report was completed;
- She educated House Managers, Staff WW, CTA-C and Staff S, RN about abuse and the proper reporting process, but did not educate Staff XX, RN (this was not documented on the PSN Report).
- She did not educate other facility-wide patient care staff about abuse and the procedure to take when abuse was witnessed.

During an interview on 04/05/17 at 3:50 PM Staff OO, RN, Quality and Technology Service Line Specialist stated that:
- Staff XX asked her if she had read the PSN report she had submitted approximately five days before related to the allegation of Staff AAA's abuse toward Patient #11 (The PSN report was directed to Staff OO because she was the leader for the unit the alleged abuse occurred on).
- When she read the PSN (five days after the PSN was submitted), she felt "it was horrible", but "abuse wasn't the first thing that came to my mind".
- She forwarded the PSN to the staffing office because they (Staff K, DON) oversaw contracted nurses.
- "It was not looked at as an abuse case", and "No one talked to me about this case."
- Staff were taught to use the abuse hotline and how to recognize outside abuse to a patient, but not trained about staff to patient abuse that could occur inside the hospital.

During an interview on 04/06/17 at 3:38 PM, Staff K, DON stated that:
- She did not interview any of the staff related to the reported allegation that Staff AAA had abused Patient #11;
- She determined that the allegation that Staff AAA had abused Patient #11 was substantiated based on the PSN report only.
- She was ultimately responsible to ensure that abuse investigations were complete, and "I did not follow policy like I should have".