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Based on interview, record review and policy review, the hospital failed to follow their policy for investigation of abuse and neglect and perform a timely and thorough investigation to accurately determine whether abuse had occurred for one patient (#50) and immediately remove two staff members from patient care after allegations of abuse were reported for two discharged patients (#50 and #105) of two allegations of abuse reviewed. These failed practices placed all patients admitted to the hospital at increased risk for their safety.

These failed practices resulted in noncompliance with 42 CFR 482.13 Condition of Participation: Patient's Rights.

Please refer to A-0145

















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Based on interview, record review and policy review, the hospital failed to follow their policy for investigation of abuse and neglect and perform a timely and thorough investigation to accurately determine whether abuse had occurred for one patient (#50). Immediately remove two staff members from patient care after allegations of abuse were reported for two discharged patients (#50 and #105) of two allegations of abuse reviewed. These failed practices placed all patients admitted to the hospital at increased risk for their safety.

Findings included:

Review of the hospital's policy titled, "Allegation of Abuse, Neglect or Harassment," last revised 12/30/22, showed:
- Patients have the right to be free from abuse or neglect (as a form of abuse) and harassment.
- All forms of abuse, neglect, or harassment whether from staff, practitioners, other patients or visitors are prohibited.
- Allegations or information indicating that abuse, neglect, or harassment may have occurred will be thoroughly and promptly investigated with appropriate follow-up action.
- Neglect is considered a form of abuse and is defined as the failure to provide goods and services necessary to avoid physical harm, pain or mental anguish.
- Abuse is a willful infliction of injury, unreasonable confinement, intimidation or punishment, with resulting physical harm, pain or mental anguish. This includes staff neglect or indifference to infliction of injury or intimidation of one patient by another.
- Verbal abuse is the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to the patient or their families within their hearing distance. Examples include tone of voice, such as yelling, screaming or arguing; harassment, threats of harm; saying things to intentionally frighten the patient.
- Employees who provide care to patients will receive abuse, neglect, and harassment mandatory training at the time of orientation and re-orientation annually. Training includes prevention, intervention, detection and related reporting requirements.
- When an allegation of abuse or neglect was received the department supervisor, or nursing supervisor would initiate the triage process immediately which included; interviewing the patient as appropriate; assessing the patient for evidence of injury, harm or mental distress; obtain written statements from the person making the allegation, any witnesses and the accused individual; then complete the assessment and notify the Administrator in charge of the patient care area to make a determination.
- If the allegation was considered credible or required further investigation, Human Resources would be notified immediately.
- As soon as the identity of the accused individual was known, the accused individual would be removed from all patient care immediately.
- The accused individual may not care for, or have any in-person contact, with any patients while the triage process and/or investigation was ongoing, and a determination was pending.

Review of the hospital's document titled, "Current Summary Multiple Issues Feedback (336625)," dated 02/07/24, showed the following:
- On 02/07/24, a grievance was submitted through e-mail by Patient #50's wife regarding several concerns. A patient advocate went to the patient room and the spouse reported all written concerns in the email were resolved.
- The email received from Patient #50's wife on 02/07/24, stated that the patient originally was admitted with renal (pertaining to the kidneys) failure, severe colitis (inflammation of the inner lining of the colon) and alcohol withdraw (symptoms that occur when someone stops using alcohol after a period of heavy drinking). During his stay in room 429, she arrived at the hospital to find him naked with only a pure wick (an external device that uses suction and a soft, flexible wick to draw urine away from the body into a sealed collection canister) attachment on, his bed pushed up against a very cold window and no bed linens within reach to cover himself. She understood that he was taking off his gown, however that was during a time when the outside temperature was below zero. She asked staff several times to move his bed away from the window. Those requests were not acknowledged until she arrived to find him naked and shivering in front of the window again. She became angry and expressed her frustration to the Nurse Assistant (NA) in the room. The NA moved him immediately and got him sheets and blankets. Patient #50 was supposed to be under constant supervision with a live sitter or a tele-sitter (caregivers that watch at-risk patients via monitor and report to the primary caregiver). On the afternoon of 01/26/24, she was not able to stay the full day and left around noon. When she left, the patient was in his recliner with a live sitter. A short time later the live sitter left and the tele-sitter was either not active or not paying attention. The patient attempted to stand on his own and suffered a hard fall to the floor, injuring his left hip/leg/ankle. Patient #50 was moved to room 214 and the quality of his care dropped again. He had been more confused and had an increase in hallucinations (seeing or hearing things which are not there). He had issues with his oxygen and carbon dioxide (CO2, a gas produced by exhaling) levels being off. He was not given his continuous positive airway pressure (CPAP, a machine that uses mild air pressure to keep breathing airways open while a person sleeps) to wear at night and his oxygen was not on. The morning of 02/06/24, she arrived at the hospital and heard his overnight nurse telling him that she would refuse to be his nurse again that night due to his behavior. The wife explained to the nurse the patient's need for oxygen, his CPAP at night and that he had increased confusion. The nurse reported to her that none of that information had been passed along to her. The night nurse explained that staff had just had to clean the patient up because he had a bowel movement in his shorts without telling anyone. After the nurse left the room, Patient #50's wife attempted to turn on the patient's television and found his call button/remote was hanging on the wall behind him and unplugged from the wall. It was not accidental as it would set off an immediate alarm that would need to be silenced. Patient #50 was left with no way to reach out for assistance when he needed to use the bed pan and had obviously sat in his stool for a long period of time because he developed a rash on his bottom and scrotum.
- Nurse management notes showed that she met with Patient #50's wife and discussed her concerns. She assured the wife that she would look into her concerns. She then spoke with the patient's Registered Nurse (RN) and NA about increasing the frequency of rounding.
- A second grievance email was sent from Patient #50's wife on 02/10/24, and showed the same concerns as the prior email with the addition of arriving that morning to find the patient naked, in a puddle of urine, with both bed rails down and half of his body hanging off the bed. Photographs were sent with the email. She moved the patient up onto the bed and called for the nurse. She felt that if she hadn't arrived, he would have again fallen onto the floor and suffered additional injuries. There was also a photograph of moldy strawberries that were included in his breakfast that morning. She stated in the email that the type of care Patient #50 received reflected negligence in addition to neglect.
- Staff VVVVV, Patient Advocate, made a note about meeting with Patient #50's spouse and reporting to her that the investigation was under review through the grievance process. Concerns and comments had been tasked to new leadership.
- Notes on 02/14/24 by Staff WWWWWW, Clinical Risk Manager, showed that there were no elements of permanent harm that made the complaint of poor nursing and negligent care a risk management liability concern. It was, however, by the email report from the spouse and pictures, very concerning for allegations of neglect. The grievance was appropriate to be reviewed and addressed as soon as possible by upper clinical leadership with regulatory review, oversight and input. There was a request to escalate the complaint to the nursing director level for awareness and there was no further action warranted from the risk management department.
- Notes on 02/15/24 by Staff VVVVV, Patient Advocate, indicated a grievance resolution letter was mailed to the patient. The complaint was substantiated and there indicated an issue with nursing care. Appropriate leadership reviewed the grievance, commented and it was closed.
- A letter was sent to Patient #50's wife on 02/15/24 apologizing for their experience and that they could not share information related to staff as it was confidential.
- Photographs received in the grievance email were not included with the requested grievance.

Review of Patient #50's medical record dated 12/31/23 through 02/13/24, showed the following:
- He was a 51-year-old male who presented to the Emergency Department (ED) with a chief complaint of dizziness, hallucinations, nausea, vomiting, lower leg weakness, bowel incontinence, and multiple falls where he hit his head. It was noted he took blood thinners.
- Past medical history included a stroke, alcohol use, alcoholic hepatitis (inflammation of the liver. The various forms of viral hepatitis are named after different letters of the alphabet), chest pain, shortness of breath, swelling, high blood pressure, high cholesterol, lupus anticoagulant disorder (a rare autoimmune disorder [a disease in which the body's immune system attacks healthy cells] that causes blood clots to form in various parts of the body and can be life threatening depending on the location of the clots), deep vein thrombosis (DVT, is the formation of a blood clot in a blood vessel that is deep under the skin), sleep apnea (a potentially serious sleep disorder in which breathing repeatedly stops and starts) and Crohn's disease (a chronic inflammatory bowel disease that affects the lining of the digestive tract).
- Nurse documentation on 02/06/24 at 5:05 AM, showed Patient #50 had a tele-sitter and his call light was within reach. Respiratory was called to check on the patient's CPAP. Vital signs were checked by the NA at 4:30 AM, 6:05 AM, and 7:27 AM. At 7:15 AM he was lying on his bed alert but did not know the time. At 9:00 AM the patient had one bowel movement recorded for the shift.
- RN and NA documentation for the night of 02/06/24 into the morning of 02/07/24 showed the patient was intermittently confused, but calm and cooperative with no significant events noted.
- A discharge summary dated 02/13/24, showed Patient #50 was admitted to the hospital for colitis and alcohol detoxification (process of removing drugs or alcohol from the body). He was given medications and then developed symptoms of severe alcohol withdrawal with hallucinations and confusion. Though he was no longer experiencing symptoms of alcohol withdrawal, he had ongoing hallucinations and intermittent agitation (state of feeling irritated or restless). He was discharged to a rehabilitation facility.

During an interview on 03/14/24 at 8:25 AM, Staff VVVVV, Patient Advocate, stated that she received an e-mailed grievance from Patient #50's spouse that listed several concerns. She went to see the patient and his spouse who told her that all concerns were resolved. Another e-mail was received a few days later with additional concerns. All the concerns were shared with leadership. She spoke with the patient's wife again and sent the grievance resolution letter. She was never able to identify what happened to the patient, but the Nurse Manager documented in the file all issues were addressed and staff had been spoken to. She did not know if any disciplinary action was given to staff. Her job was only to notify the appropriate staff and communicate with the patient.

During an interview on 03/14/24 at 8:45 AM, Staff WWWWWW, Clinical Risk Manager, stated that she looked at the grievance from a liability standpoint and made leadership aware. Those type of issues were spearheaded by regulatory staff, patient safety staff and leadership staff. That was their job. She did not know the outcome of the grievance investigation.

During an interview on 03/14/24 at 8:50 AM, Staff MMMMMM, RN, stated that she was the charge nurse for the 200 unit on 02/06/24 and 02/07/24. They had just finished up their night shift when the NA reported to her Patient #50's wife was upset. The wife reported she found her husband hanging off the bed, naked, cold, with his call light tucked under the bed and unplugged from the wall. The wife showed her a picture on her phone of the situation Patient #50 was in when she arrived. She listened to the wife's concerns and started an incident report. She reported the issues to Staff V, Nurse Manager, and the RN assigned to him that day. The decision was made to round more frequently on the patient. The night shift RN had already left for the day, so she did not speak with her. She felt the call light being unplugged from the wall had been an accident.

During an interview on 03/14/24 at 9:05 AM, Staff V, Nurse Manager, stated that she was told about the incident with Patient #50 and that everything had been corrected. She looked into the concerns and no staff were aware of the call light being unplugged from the wall. Nursing staff were giving report to one another and the night nurse told the day nurse that she would be requesting a different team, but did not berate the patient. Patient #50's wife must have overheard their conversation and become upset. Patient #50 was a handful and the nurses discussed that. She did not know how long the call light had been unplugged from the wall. All call lights flashed above the room and made an obnoxious noise when they were unplugged from the wall.

During an interview on 03/14/24 at 9:20 AM, Staff I, Director of Nursing (DON) and Staff EEEEEE, Chief Nursing Officer (CNO), stated that Staff V, Nurse Manager, did the grievance investigation. Typically, if allegations contained a neglect or abuse element, they became a part of the investigation. The allegations did not go through the correct channels. Staff EEEEEE stated that there was a process problem because the grievance was not entered correctly from the beginning. The grievance investigation did not follow the abuse and neglect policy. Staff should have acted faster, and it was never brought to her attention. Staff I stated that she had been tasked several days after the grievance was submitted. She did see the call light had been unplugged, but felt it was accidental and not willful. Staff just forgot to plug it back in to the wall. She did not know how to turn off a call light alarm and did not know how long it had been unplugged from the wall. The whole story did not make sense. An investigation had been done but did not follow the abuse and neglect investigation protocol.

During an interview on 03/14/24 at 10:20 AM, Staff LLLLLL, Administrative Director of Quality and Safety, stated that there was no way to determine how long Patient #50's call light had been unplugged from the wall.

During an interview on 03/14/24 at 2:00 PM, Staff AAAAA, RN, stated that she was the primary RN taking care of Patient #50 on the night shift of 02/06/24 into 02/07/24. Patient #50 was an alcoholic who transferred to their unit from another floor. The patient had been confused but remembered his medications well. He told her when he needed his pain medication and wanted it a certain way. Patient #50 whistled and yelled for her and then told her he didn't need anything, he just wanted to make sure someone was there. The whole night went that way. She was giving report to the day shift nurse when they heard Patient #50's bed alarm go off. They stopped report and went into his room. They found the patient trying to get out of bed and he had his legs looped through the bed rails. It took three staff members to reposition him and get him untangled. The patient was confused, tried to leave and kept telling her he wanted tequila. The wife entered the room and became upset. Staff AAAAA told the wife about the night they had and answered all of her questions. The call light was never unplugged from the wall. There was no way to unplug a call light without it making a loud, alarming sound. The call light would have only been unplugged from the wall in the case of an emergency. She never requested a different team or to not be Patient #50's nurse.

During an interview on 03/18/24 at 3:45 PM, Staff RRRRRR, NA, stated that she was assigned to Patient #50 for the night shift beginning on 02/06/24. She never had a conversation with his wife about his care. He was not a difficult patient and not very active. He pretty much just slept. She did not know anything about his call light being unplugged from the wall.

During an interview on 03/14/24 at 10:50 AM, Staff X, RN, stated that she was Patient #50's nurse the day of 02/07/24. She did not know anything about his call light being unplugged from the wall. Patient #50's spouse had been upset that day and felt the night staff had not taken care of Patient #50. Patient #50's spouse was very nice and very thankful for her husband's care. No one from leadership interviewed her or asked her any questions about the incident.

During an interview on 03/18/24 at 2:30 PM, Staff QQQQQQ, NA, stated that she had taken care of Patient #50 on the day of 02/07/24. She did not remember ever being told a call light had been unplugged from the wall. Patient #50's wife never spoke to her or reported concerns during his stay. There was a way to silence the alarm when the call light was unplugged from the wall.

Review of the hospital's documents titled, "Current Summary 337628," and "Current Summary 337637," both dated, 02/23/24 showed the following:
- On 02/22/24, Patient #105 made an allegation that Staff TTTTTT, Physician, touched her inappropriately.
- On 02/22/24, at approximately 6:00 PM, Staff TTTTTT was notified of the allegation and told that the care of Patient #105 would be transferred to Staff UUUUUU, Physician.
- On 02/23/24, at 7:30 AM, Staff TTTTTT was contacted by phone where he reported nothing inappropriate had occurred. He reported that the patient was upset about her upcoming discharge.
- On 02/23/24, Staff UUUUUU was contacted "to discuss her impressions. Agree with her recount of the events as described."
- On 02/23/24, Staff GGGG, Customer Service Supervisor, documented that he and a Patient Advocate spoke with Patient #105 and she reported Staff TTTTTT was "feeling her on her thigh and progressed up" and that he was "on the bed with her rolling around." The patient gave the impression that these events happened more than one time that week.
- The patient was in a semi-private room with a roommate.
- The patient reported that her two friends were in the room at the time of the alleged event.
- Staff GGGG, Customer Service Supervisor, copied and pasted an excerpt from the patient's medical record, documented by the Nurse Manager, that stated the patient was "intermittently confused and did not remember provider rounding" and that the nurse "reminded patient of provider round this morning when her daughter was present."
- On 03/06/24, the allegation was noted as unsubstantiated and a resolution letter was mailed to the patient.
- There were no documented statements from the patient's roommate, any possible witnesses, Staff UUUUUU, who took over care of the patient, or the accused individual Staff TTTTTT.
- Staff TTTTTT was removed from Patient #105's care but not removed from all patient care.

Review of Patient #105's medical record showed:
- She was a 58-year-old, admitted on 02/18/24 for pneumonia (infection in the lungs) and difficulty breathing.
- On 02/18/24, a History & Physical (H&P) showed she was alert, oriented and cooperative with an appropriate mood & affect.
- On 02/22/24, a Progress Note showed she had no surviving relatives. She was alert, oriented and cooperative with an appropriate mood & affect.
- On 02/23/24, a Discharge Summary showed she had no next of kin. She was alert, oriented and cooperative with no focal deficits.

During an interview on 03/14/24 at 10:28 AM, Staff GGGG, Customer Services Supervisor, stated that his role in Patient #105's reported allegation was to gather information for the incident report, interview the patient and notify the proper departments, which in that case was Regulatory and the Medical Director. "When there are allegations of abuse or neglect against a physician, due to the nature of the allegations, we step back and let the appropriate parties do their investigation."

During a telephone interview on 03/14/24 at 12:20 PM, Staff UUUUUU, Physician, stated that when an abuse or neglect allegation was made against a physician there would be an immediate investigation "within 24 hours." An emergency meeting would need to be held "if there was a real concern that the abuse or neglect happened." If there was an immediate concern, the physician would be suspended. She was unsure what the hospital's abuse and neglect policy stated. Her "assumption would be that if it was needed, the physician in question would be taken off duty immediately, depending on the allegation." In the case of Staff TTTTTT, he was removed from that patient's care and the investigation was handled by his supervisor Staff OOOOOO.

During an interview on 03/14/24 at 1:00 PM, Staff OOOOOO, Physician, stated that when he was notified of an allegation of abuse against a physician, he reviewed the complaint, met with the patient if they were still in the hospital, and had a one-to-one conversation with the physician in question. That conversation would be "documented and then it's over." He stated he kept notes to show when he had met with a physician after an allegation and he would refer to those notes to see if there were patterns of behavior. He stated he had "been doing this for 12-15 years, and as a Director, I have never removed anyone from patient care." He discussed this specific allegation regarding Patient #105 verbally with Staff TTTTTT. Staff UUUUUU "and others were in agreement that no further intervention was needed." When asked if the abuse and neglect policy that stated all staff accused of abuse or neglect would be removed from patient care until a determination was made, applied to physicians; he replied "blanket policies, like this, are preposterous." He added that he knew Staff TTTTTT very well, and given a disability that the physician had, it would have been physically impossible for him to do what the patient alleged.

During concurrent personnel file review and interview on 03/15/24 at 10:00 AM, Staff VVVVVV, Medical Staff Manager, stated that Staff TTTTTT, Physician, had not received training on abuse and neglect since 2017.



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