HospitalInspections.org

Based on document review and staff interviews, the acute care hospital's administrative staff failed to ensure staff followed the hospital's policy regarding delay in communication to the appropriate staff in the allegations of abuse for 1 of 1 reported incidents of possible dependent adult abuse (Patient #1) on Medical Surgical 3rd floor Unit. Failure to follow the hospital's policy on the report of suspected abuse could potentially result in the hospital staff failing to immediately respond to a report of suspected dependent adult abuse allowing the hospital staff to prevent patients from experiencing harm following suspected abuse. The hospital administrative staff identified a census of 169 patients upon entrance.

Findings include:

1. Review of the policy "Suspected Dependent Adult and Child Abuse-Case Management" Effective 2/2021, revealed in part, " ...Report the suspected abuse to the immediate supervisor or a licensed clinician of the area ...Notify attending/treating physician of suspected abuse."

2. During a review of the medical record and review of investigation for Patient #1 revealed the following series of events:

a. On 4/8/23 at 4:43 PM Patient #1 arrived by ambulance to the Acute Care Hospital Emergency Room right sided weakness and left sided facial droop. Patient #1 was unable to communicate due to an ischemic stroke (occurs when the blood supply to part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients).

b. On 4/8/23 at 7:41 PM Patient #1 was then admitted to Medical Surgical Unit 3rd floor.

c. On 4/12/23 at 4:00 PM Patient #1 was placed on telesitting (a computerized system that can monitor via camera and audio) due to multiple attempts in pulling out intravenous lines (IV).

d. On 4/19/23 at 1:58 PM Patient #1 entered in to surgery to have a percutaneous endoscopic gastrostomy tube, (PEG tube, a procedure in which a flexible feeding tube is placed through the abdominal wall and into the stomach). PEG tube is a feeding tubes are needed when someone is unable to eat or drink.

e. On 4/28/23 at approximately 3:00 PM Visitor Z entered Patient #1's room leaned into the Patient #1's face and slapped him three times then slapped his leg, grabbed his right arm causing Patient #1 to moan and then told him he stank and needed spray.
Telesitter A and Telesitter B witnessed the event. Telesitter A immediately notified Registered Nurse (RN) E of event. RN E did not respond immediately to Patient #1's room.

f. RN E arrived sometime after incident and Visitor Z had already left for the evening.

3. During an interview on 6/15/23 at approximately 9:00 AM, with RN E revealed they did not respond immediately to Patient #1's room after Telesitter A contacted them because they were busy with another patient and when they entered Patient #1's room, Visitor Z was not present and Patient #1 had no redness or marks on their body. RN E revealed they did not contact their supervisor or the provider on call because they did not witness the event. The medical record lacked documentation indicating that Patient #1's nurse notified Patient #1's physician on 4/28/23 and that Patient #1 was assessed for visible marks due to reported accusation of Visitor Z assaulting Patient #1.

4. During an interview on 6/15/23 at approximately 9:30 AM, with RN Manager F revealed that on 5/1/23, she had received a phone call from RN D stating RN D overheard Telesitter C telling a Patient Care Technician (PCT) there was a visitor in Patient #1's room that had slapped Patient #1 several times last week. RN Manager F verified that RN E did not report this incident to any supervisors nor providers. RN Manager F immediately contacted House Supervisor G making a joint decision to remove and restrict all visitors until the investigation was complete and move Patient #1 to another room for safety.

5. During an interview on 6/15/23 at approximately 10:15 AM, with the Regional Director of Risk Management revealed that during the Acute Care Hospitals investigation RN E did not follow hospital policy for reporting suspected abuse of a dependent adult. The Regional Director of Risk Management and RN Manager F acknowledged Telesitter A should have notified the House Supervisor if RN E did not respond immediately and the provider should have been notified immediately per hospital policy.